Center for Medicinal Mindfulness
Psychedelic Safety Assessment
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Introduction
Taking this assessment is required before participating in any medicine related events or services with Medicinal Mindfulness.  The questions may also be part of a structured psychedelic safety assessment interview to participate in ongoing classes, psychedelic therapy, or our training program.  Please return before your scheduled session and contact your facilitator with any questions.

A Few Notes About the Assessment:

Psychedelic experiences are very safe, but they are not for everyone. This assessment is for your own safety, nothing more. Please be honest with yourself and us. Answering “yes” to any of the safety questions below may indicate a need for additional support before participating in a medicine related experience. A “yes” answer does not automatically disqualify you from our services. It is an opportunity to discuss safety, and to help your facilitator create the necessary preparation and integration support, and the safest and most meaningful container for your experience.

Although most experiences are positive and deeply meaningful, truthfully answering “no” to every question does not guarantee an easy or enjoyable experience. Although positive outcomes are common, exploring the material evoked by these medicines is sometimes difficult to do. Your facilitator is here to support you throughout the process.

Contraindications [reasons not to participate in a medicine related experience] are included in the specific service’s participation agreement and listed in the questions.  With the right support, private individual sessions or small groups can be facilitated to treat significant clinical concerns that might not be easiest to engage in a large group setting or training program.  Speak to your therapist or facilitator if you have any questions.  

Again, these events are very safe, but they are not for everyone.  Please be honest with yourself and us regarding your readiness for exploring psychedelic medicines. We are here to support you through this decision-making process. All information provided is confidential and stored in a HIPAA protected drive or secure filing system.

If you have any questions regarding safety you can email us at safecommunity@medicinalmindfulness.org.


Name: *
Age *
Email: *
Phone number: *
Emergency Contact Name: *
Emergency Contact Phone Number: *
Emergency Contact's Relationship to You: *
1.  Are you pregnant or nursing? *
2.  Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this program? A psychedelic experience is not appropriate for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy. If yes, please describe: *
3.  Have you ever been diagnosed with, or required significant treatment for, a psychological or emotional disorder, or for any other psychological or emotional reason?  If yes, please describe.   *
4.  Have you ever been hospitalized for a psychological or emotional disorder, or for any other psychological or emotional reason? If yes, please describe: *
5.  Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically, emotionally or otherwise? If yes, please describe: *
6.  Has a health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or using altered states practices? If yes, please describe: *
7.  Have you ever experienced extreme paranoia, anxiety, panic attacks, or other extreme negative experiences while using cannabis, any psychedelic medicines, or during any other time in your life that required a significant intervention?  If yes, please describe: *
8.  Have you ever dealt with a pattern of unstable relationships that caused you significant distress?  If yes, please describe: *
9.  Have you ever fainted or blacked out or otherwise adversely lost consciousness  while on cannabis or any psychedelic medicine?  If yes, please describe: *
10.  Have you ever had extremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep for days or racing thoughts, or alternatively extremely low energy) after the effects of a psychedelic or cannabis should have worn off?  If yes, please describe: *
11.  Have you ever seen or heard things or people that weren’t there after the effects of a psychedelic or cannabis should have worn off?  If yes, please describe: *
12.  Have you ever obsessed over an idea or belief in a way that has caused difficulties in your life?  If yes, please describe: *
13.  Do you have any acute, current or past substance abuse/dependence issues?  If yes, please describe: *
14.  Are you currently on any medications, supplements or recreational drugs that could affect you safely participating in a psychedelic experience?  (If you don’t know, please list and we will review with you.)  If yes, please describe: *
15.  Do you have a history of disruptive or violent behavior, either physical or emotional? If yes, please  describe:
16.  Do you have a history of traumatic or difficult life events that has not been addressed or is not being supported therapeutically? If yes, please describe: *
17.  Do you have any past or present concerns around suicide or self-harm? If yes please describe: *
18.  As you contemplate attending this experience, or when checking in with yourself right before it begins, are you extremely anxious? If yes, please list and describe: *
19.  Have you recently had a major transformational experience, with a psychedelic medicine or otherwise, that feels almost complete but not quite, or unresolved? If yes, please describe: *
20.  Do you ever feel extremely uncomfortable in group transformational processes? If yes, please describe: *
21.  Are you currently employed, a student, or otherwise financially stable?  If yes, please describe: *
22.  Do you have a safe home environment and a stable residence??  If yes, please describe: *
23.  Have you ever been or are you currently involved in any legal proceedings? Criminal or civil? If yes, please describe: *
24.  Anything else you think we should know about? Use the space to include any additional comments, questions or concerns. *
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