HAF: Psilocybin Service Centers Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please ONLY COMPLETE THIS SURVEY if you are interested in OPENING A SERVICE CENTER and want to be added to our Service Center email list and Slack channel.

If you have questions or want information about other areas of our work, please contact us through our website and we will get back to you. Thank you!

Your Name *

Phone Number *

Email *

Name of Service Center *

Do you or your team have any of the following experience? (Check all that apply)

All answers will be for our internal records only.

Owned and/or managed a business

Clinical background - i.e., treating clients in a medical or licensed mental health context

Experience administering psychedelic-assisted therapy

Experience treating clients for non-clinical wellness services (e.g. yoga, meditation)

Where are you interested in opening a psilocybin service center? (City or Town) *

What stage of development are you in? *

I'm considering opening a service center

I am definitely opening a service center, but have not yet begun developing it.

I have incorporated my organization and am already developing it and hiring staff.

My service center is ready to go, I am working on my OHA application.

I've submitted my OHA application

Other:

Where are you at in securing a location (executed lease or purchased property) for your service center?

I have a location/property for my service center secured

I am currently looking for a property for my service center

I have not started looking for a location yet

Clear selection

Number of rooms for psilocybin sessions at your location (if you've secured a location):

What types of dosage are you interested in offering?

Full dose

Microdose

Both full dose and microdose

Clear selection

Clear form

Never submit passwords through Google Forms.

This form was created inside of Healing Advocacy Fund. Report Abuse

Forms