Name *

First Name

Last Name

Phone *

(###)

###

####

I attest that I am 21 or older. *

Yes

No

Have you taken Lithium in the last 30 days? *

Yes

No

Are you currently having thoughts of causing harm, or wanting to cause harm, to self or others? *

Yes

No

Do you have a history of causing harm, or wanting to cause harm, to self or others? *

Yes

No

Have you ever been diagnosed with active psychosis or treated for active psychosis (schizophrenia, etc.)? *

Yes

No

Are you able to travel to Portland to conduct your psilocybin dosing session. (Preparation & Integration Sessions can happen over video/call.) *

Yes

No

Have you had an allergic reaction to mushrooms or other fungi in the past?

Yes

No