Name *

First Name

Last Name

Phone *

(###)

###

####

Birthday

MM

DD

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Have you taken other psychedelic/entheogenic substances before?

Check all those that you've taken.

Ayahausca

Psilocybin

LSD

DMT

5MEO-DMT (Bufo)

Mescaline (San Pedro, Peyote)

Cannabis

Ketamine

Iboga, Ibogine

Other

Do you have any serious heart, liver, or kidney conditions?

Yes

No

Have you had surgery, concussion, or a head injury in the past 6 months?

Yes

No

Are you engaged with therapy/treatment by a psychologist, psychiatric doctor or therapist?

Yes

No

Do you have any history of psychiatric disorders (borderline personality disorder, schizophrenia, bipolar, psychosis, etc)?

Yes

No

Let's Discuss

Have you engaged in any intentional self-harm or had suicidal thoughts in the last year?

Yes

No