Entheogen Experience Application

Please complete the following form to help us understand your background, intentions, and any considerations necessary to support your participation in our microdosing program. All information will be kept confidential.

Name

Intention

What are your primary reasons for participating in this microdosing program? For example: personal growth, mental health support, creativity enhancement, spiritual development.

Do you have specific goals or outcomes you hope to achieve over the 10 week program?

Health and Medical History

Do you have any pre-exisiting Medical Conditions? (e.g., hypertension, diabetes, epilepsy)

Are you currently taking any medications? Please list

Mental Health History: Have you been diagnosed with any mental health conditions? If yes, please specify.

Are you currently receiving therapy or counseling?

Substance Use: Do you use tobacco, alcohol, or other substances? If yes, please describe frequency and quantity.

Do you have any allergies?? (Including food, medication, environmental)

If you have any other relevant health or medical information, please share below.

Lifestyle and Support

Diet and Nutrition: Do you follow a specific diet or have dietary restrictions?

Exercise and Physical Activity: Please describe your regular physical activity routine.

Support System: Do you have a support network (friends, family, community) that will be aware of your participation in this program?

Experience with Entheogens

Have you previously engaged in microdosing? If yes, please provide details (substance, dosage, duration, effects).

Have you had any prior experiences with psychedelics at higher doses? If yes, please share.

Additional Information

Do you have any concerns or questions about participating in the microdosing program?

What are your expectations from the facilitators and the group during this program?

Please share any final thoughts, comments, concerns, if relevant.

By submitting below, you acknowledge that the information provided is accurate to the best of your knowledge and consent to participate in the microdosing group program.