Women's Microdosing Community Application

Please answer all questions accurately and honestly. All information is confidential and for the purpose of helping me to better serve you.

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Which group would you like to join?
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First and Last name
Address
Date of Birth
Phone
Gender
Email
Emergency Name and Contact
Height & Weight
Do you have any allergies or intolerances?   

Please describe what you are allergic or intolerant to. Inclusion of the type of reaction experienced and if treatment was necessary is helpful. 

Have you ever been diagnosed or suspect you have any of the following medical conditions?

Please list any other medical conditions you may have currently or have had in the past as well as further describe medical conditions, particularly for conditions listed in the previous question. 

Have you had an operation or surgery of any kind? If yes, what type of operation and when?
Are you pregnant or breastfeeding?

Have you ever been diagnosed or suspect you suffer from any of the following psychiatric conditions?

Please use this place to describe any psychiatric condition you have or suspect you suffer from. 

If you have ever been hospitalized for a psychiatric reason, please describe further including how many times, for what reason(s), and when: 

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If you have experienced suicidal thoughts or attempted self harm, please describe these thoughts or actions further here: 

Do any of your family members suffer from severe mental illnesses such as bipolar disorder, schizophrenia, or another serious condition? If so, please describe here: 

Please include a complete list of your prescription medications including the drug NAME, DOSE, FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome. 

Please include a complete list of your over the counter medication, supplements, and herbal products including the NAME, DOSE, FREQUENCY of use. Inclusion of any notes on effectiveness, side effects, or other desires and intentions regarding their use is welcome. 

Are you currently working with or ingesting any plant or earth medicines? If so please indicate what you are working with, dosage, frequency of use and the reasons for your use of the medicine. 

How often do you use alcohol:

Do you have any fears or phobias? Please list symptoms and treatments.                            

Do you smoke or use tobacco products?

Please describe the type(s) of tobacco products used, how often you've used them, and in what quantity they're used. 

Have you used any of the following substances in the past 3 months?

Further description of substances used if applicable

How much and how often of each substance? 

Do you have a drug or alcohol addiction? If so please specify 

Have you used psychedelics previously? 

Current Intention(s) for microdosing psychedelic use 

Please describe the reason(s) you're considering use of microdosing psychedelics or exploring them further 

What are you hoping to receive from microdosing psychedelics? 

How would you like to feel, think, or act different as a result of microdosing that is different from how you currently feel? 

Please describe any questions or topics regarding elements of this intake form or psychedelic use that you'd like to specifically address 

Which of the following describes your current relationship status?

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Which of the following best describes your work situation?

If working, what is your occupation? 

Are there any major sources of stress in your life at the moment or events that have occurred recently that have impacted your health? Example: workplace struggles? Toxic relationship? Death or loss of close persons or relationships? Changes to health or new diagnoses? Ongoing stressors etc 

Which of the following do you consider your support network?
How would you describe your spiritual background or spiritual path?

Survey of Depression Symptoms: 

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