Welcome

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Area Code

Phone Number

4

Age

5

Have you had prior experience with psychedelics?

No

Yes - limited

Yes - moderate

Yes - exetensive

6

What is drawing you to explore a psychedelic experience at this time?

7

What are you hoping this experience may support?

Personal insight and/or growth

Emotional healing and/or release

Life transition and/or clarity

Spiritual/Existential exploration

Overall mental health

Other

8

Have you ever been diagnosed with a mental health condition

Yes

No

9

If you answered yes to the previous question, please check any that apply* This field is required.Past or present

Anxiety

Depression

Trauma/PTSD

Bipolar Disorder

Psychosis or Schizophrenia Syndrome

Substance use concerns

Other

10

Are you currently taking any prescription medications?

Yes

No

11

Do you have any significant medical or health conditions we should be aware of?If no, just write no. If yes, please describe below.

12

Do you currently work with a therapist or mental health provider?

Yes

No

13

If you are working with a therapist/mental health care provider, are they aware and supportive of this exploration?

Yes - they are aware and supportive

Somewhat - they are aware but not fully supportive

They are not aware of this exploration

Not sure

14

Do you have supportive people in your life who are aware of this interest?

Yes

Some

No

15

Final Acknowledgement (By signing, you agree to the following statements)I understand that completing this form does not guarantee eligibility and that additional screening, preparation, and informed consent are required prior to participation. I understand that psychedelic services offered through a micro-healing center are not a substitute for ongoing medical or mental health care.

Powered by Jotform SignClear