Intake form for a psilocybin ceremony in 2024

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Please take a couple of minutes and answer the questions below truthfully. Your answers are a very important part of the process and are fully confidential. After receiving your information you will be contacted you via email to schedule an intake-guidance call to finalize your participation.
Please make sure to get acquainted with the ceremony costs first.

Email *

Name and surname *

City you are currently living *

Country of origin *

Telephone number (including prefix) *

Date of birth *

YYYY

Which group ceremony date would you like to join? *

16th of March '24

1st of June '24

I am interested in private ceremony

Required

I am acquainted with the costs of the ceremony (you can check them here at the bottom of the page under the paragraph 'price') *

Yes

Required

Do you have a history of psychological or medical treatments? *

Are you currently being treated by a therapist or a physician? If yes, please share more details.
*

Are you using any prescribed medicine or homeopathic medicine at the moment (including pain relief or nose sprays)? If yes, what and why?
*

Do you use any of the substances below? *

Alcohol

Cannabis

Hallucinogens (psilocybin mushrooms, dmt, lsd, etc)

Opiods (heroin, codeine, morphine, ocycodone, etc)

Sedatives/hypnotics/anxiolytics (valium, xanax, restoril, diazepam, ativan, etc)

Stimulants (cocaine, ecstasy, speed, methamphetamine, ritalin, concerta, biphetamine, dexedrine, etc)

Antipsychotics (clozapine, haloperidol, pipamperon, resperidon, etc)

Heart-medication

I use non of the above

Other:

Required

If you selected any of the substances above how often do you use them and when was the last time? *

Do you have any experience with psychedelics like Ayahuasca/Truffles/Wachuma or others? If yes, please share when and where, how many times and what your general experience was. *

On a scale 1-5 please describe your mental stage *

I feel at peace

Very depressive

I am haunted by memories, flashbacks, or nightmares about a certain event
*

Strongly disagree

Strongly agree

I have trouble connecting with people
*

Strongly disagree

Strongly agree

The sadness I feel makes it difficult for me to function in my personal, social, or work life
*

Strongly disagree

Strongly agree

What is your motivation/intention to join the ceremony? What would you like to heal or achieve? *

How would you describe yourself in a few sentences? *

What is your profession/ what do you currently do for a living? *

Do you use any self-care tools (like meditation, yoga, sport, breathing techniques etc)? If yes, what is it? *

I confirm that I am not experiencing any of the conditions below (please mark all that you are not experiencing) *

Pregnancy

Schizophrenia (nor any of your family members of the first or second category)

Bipolar disorder (nor any of your family members of the first or second category)

Borderline personality disorder (nor any of your family members of the first or second category)

Psychosis susceptibility syndrome (or history of psychosis)

Severe blood pressure/heart complaints

Required

Is there anything else you would like to share?

I am aware that participation in a ceremony is my own responsibility. I will adhere to the dietary guidelines and I am aware of any diseases/conditions that pose a risk when using truffles. I will adhere to the safety regulations specified by the guide; I will not leave the ceremony room/site without permission from the ceremony leader, as long as I am under the influence of truffles.
*

Yes

Required

I have read and agree to the cancellation policy included with this intake. Read about cancellation policy here.
*

Yes

Required

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