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Profession *
Are you currently, or in the last month, taking any prescription medicines? If YES, list all medications, making sure to specify dosage and duration of use, as well as all reasons/conditions for all medications: *
Do you have any medication allergies? If YES, list all allergies and reactions: *
Do you have any food allergies or restrictions? If YES, list all allergies and reactions: *
Do you have any known mushroom or plant medicine allergies? If YES, list all allergies and reactions: *
If you check any symptoms, please provide details, including dates and treatment(s): *
Are you pregnant, planning to become pregnant and/or breastfeeding? *
Do you have any physical disabilities or handicaps? If so, please describe along with what assistance you may need. *
Do you have or have you ever had heart issues? If yes, please provide details, including dates and treatment(s): *
Have you, or any member of your family, been diagnosed with or experienced depression, anxiety, post-traumatic stress, substance misuse, obsessive compulsive disorder, or an eating disorder? If yes, please provide details, including dates and treatment(s): *
If yes to any, please provide details, including dates and treatment(s): *
Do you have or have you ever had any mental conditions which you feel has affected you in a less than optimal way? If yes, please provide details, including dates and treatment(s): *
Have you ever received a diagnosis of Post traumatic stress disorder (PTSD): If yes, please provide details, including dates and treatment(s): *
If yes to any, please provide details, including dates and treatment(s): *
Have you seen in the past, or are you currently seeing, a therapist or a mental health professional? If yes, when was the last time you saw them and/or how often do you see them? *
What are 3 words you would use to describe your childhood? *
Do you have a relationship with a behavior or a substance that you would like to change? If yes, please describe: *
Do you have any immediate concerns or pressing matters? If so, please describe *
Who or what supports you and where do you turn for support? Can you discuss your feelings openly with these people and rely on them for support, resources, and strength? *
Are they aware of your intention to participate in a journey and are they willing to support you during the integration period upon your return home? *
Have you ever had a challenging experience with a psychedelic or recreational drug? If so, please describe: *
What are your intentions (not expectations) for participating in this program, as it can be valuable for you to clarify the reasons you are doing this work? *
Do you currently have a mindfulness practice (journaling/meditation, etc?) If so, please describe: *
How do you nurture yourself and what are your self-care practices? *
What do you want to learn about yourself? *
How can this experience help you evolve into your higher self? *
Is there anything else you would like us to be aware of or any specific questions you have?
