Name
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First Name
Last Name
Email
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Why are you interested in working with plant medicine?
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Please select all that apply.
What are your intentions and goals in this experience? What challenges are you hoping to work through?
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Please list history of mental health.
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depression, PTSD, anxiety, autism, etc. Self diagnosis is okay here.
Are you currently taking any prescriptions or medications? Please list below if so.
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Have you or has any one in your family ever been diagnosed with psychosis, schizophrenia, or other psychotic disorders?
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If yes, please describe.
Do you have any experience with psychedelics?
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yes
no
Do you have any experience with microdosing?
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yes
no
Please briefly describe your experience with psychedelics.
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Please share anything else you would like to share with us.
Please confirm that you understand, agree and consent to the following by marking each box.
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