Psilocybin Application Form Psilocybin Application Form Step 1 of 5 20% SERIOUS ENQUIRIES ONLY. Expect us to call for pre-consultation info.Please note that EVERY field must be filled out for you to be able to submit this form. Please complete this application ONLY if you are fully committed to participating in this treatment program. We contact you within 24 hours to arrange a telephone call and it is important you be available during that timeframe. Thank you for being genuinely ready and respecting our time and resources. Please click the box below to indicate you understand and agree:* I understand and agree Name* First Middle Last Age*Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Weight* Body Mass Index* Height* City & State/Province* Gender* Phone*Email* Emergency contact info* Profession* Reason to be drawn to work with Psilocybin ? (please elaborate)*Medical InformationPlease answer these questions honestly and to the best of your knowledge. 5 MeO DMT is a powerful entheogen and has some physical, psychological and pharmacological contraindications. We need to know if there are any concerns in order to assess if this work is safe or appropriate at this time.Do you have a history of or presently have any medical conditions, chronic illness or disabilities?*Do you have a history or epilepsy or seizures?*Do you have high blood pressure?*Have you ever had any heart conditions at all?*Have you ever had any brain conditions or traumatic head injuries?*Have you ever had any liver or kidney conditions?*Do you or have you had any respiratory conditions?*Do you have any tumours?*Have you ever experienced serotonin syndrome or toxicity?* MedicationsWhat medications are you talking if any? Or in the last 90 days?*Are you presently taking any of the following?* Antiemetics Antihistamines Antipsychotics Mood stabilizers ADHD medications Weight loss aids SSRI's, SNRI's, SPARI's, SRA's, TCA's Blood pressure medications Antidepressants Anti-anxiety medications Steroids Sleeping aids Immune suppressants CYP2D6 inhibitors Lithium Triptans Ergotamines Serotonin 3 receptor agonists Analgesics Gabapentin None of the above Are you presently taking any of the following Supplements or Vitamins?* Melatonin 5HTP St. John's Wort L-Tryptophan SAMe Garcinia Cambogia Ashwagandha Syrian Rue None of the above Please describe any conditions checked above*Are you pregnant, breast feeding or trying to conceive?*Please list any allergies* Psychological HistoryHave you ever been hospitalized for psychological reasons or been court ordered to see a psychiatrist or psychologist?*Have you ever used medications to manage your psychological state?*Have you or your immediate family ever had a history of schizophrenia?*Have you ever had a diagnosis of Bipolar Disorder?*Have you ever had a diagnosis of Borderline Personality Disorder?*Do you have a history of Psychosis or Mania?*Have you ever been diagnosed with Narcissistic Personality Disorder?*Have you ever been diagnosed with Obsessive Compulsive Disorder?*Are you currently experiencing or have a history of experiencing depression? If yes, please elaborate.*Are you currently experiencing or have a history of experiencing anxiety?*Are you currently feeling suicidal?*Are you currently living in a safe, stable and supportive environment?* Psychedelic, other drugs and alcohol useHave you ever worked with Psilocybin before?*What has been your past psychedelic use, if any?*Are you currently using any opiates (including tramadol, tapentadol, methadone or meperidine)?*If you consume alcohol, how often and how much do you drink?*Personal HistoryChildhood homelife: Where did you grow up? Are your parents separated/divorced? Who was in your household growing up?*Who was your primary caregiver growing up? How was your relationship with them?*How was your father's parenting style?*How was your mother's parenting style?* Where did you go for safety when you were upset as a child?*Have you experienced or been witness to a traumatic event? Can you describe what happened?*How has this traumatic experience affected you? Do you have flashbacks, nightmares or fear that arises due to the event?*What emotions, if any, came up as a response to the trauma?*How mild, moderate or severe would you say your trauma is? Does the trauma still have you in a raw vulnerable place at this moment in your life?*Have you ever reached out for professional mental health support to process the trauma? Has it been supportive?*Are there any words, language, sounds, songs, touch, gender or anything else that you're aware or that triggers the trauma for you?*Is there anything that we should know to best support you?*Personal PreferencesDo you have any dietary preferences?*Do you have any dietary allergies?*Do you have any aversions or sensitivities to touch?*Do you have any aversions or allergies to scents?*Do you have any aversions or allergies to animals?*Do you have any questions or concerns regarding your session?*Is there any additional information that you would like us to know?*How did you learn about us?* Facebook Instagram LinkedIn Google Ads Google reviews A directory Other If you checked A directory or Other above, please elaborate here:I agree to receiving further info and updates from the monthly newsletter (you can unsubscribe any time.)* Yes Inner Realms Center honours the confidentiality of information obtained about clients. Any information given here is strictly confidential.PhoneThis field is for validation purposes and should be left unchanged. Δ
