Name * First Name Last Name Email * Have you taken the prescription drug Lithium in the last 30 days? * Yes No Are you currently being treated by a medical, clinical or other healthcare provider for a medical, mental health, or behavioural health condition? * Yes No If so, please describe the condition Have you ever had an allergic reaction to consuming mushrooms or other fungi? * Yes No Are you currently taking any medications that might need to be consumed during an administration session? * Yes No If so, please list here: Are you having thoughts of causing harm, or wanting to cause harm, to self or others? * Yes No In the past Have you ever been diagnosed with active psychosis or treated for active psychosis? * Yes No Are you pregnant or feeding with breast milk? * Yes No Would you like to share any other conditions, sensitivities or health concerns with your facilitator? Would you like to share anything about your mental health history, including traumatic experiences that you feel would be helpful for an administration session? Would you like to share anything about specific behaviors, internal or external stimuli (“triggers”) that could cause you to be uncomfortable during an administration session? Would you like to share anything about your history of substance use, including current substance use, that you feel would be helpful for an administration session? Would you like to share any past experiences with psychedelics or altered states of consciousness? Thank you!
