Psychedelic Health Equity Initiative Field Map/Database Submission
Thank you for taking the time to complete this form. The data you share here will be included in our field map and eventually be housed in a publicly searchable database. Our goal is to create useful and connective tools for increasing equitable access to psychedelic assisted therapy for marginalized communities. Our field map and database aim to increase connection between the leaders and organizations carrying the psychedelic health equity movement as well as connect those players to the community at large.

If you have any questions about the form please contact the project manager @ mary@psychedelichealthequity.org
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Organization's Name *
Organizational Leader(s) *
First and last name of revenant leader(s)
Organizational Contact *
First and last name
Organizational Contact Email *
Organization's Phone Number *
Please check all the marginalized groups your work impacts. 
 *
Required
Description of project/organization
 *
Mission, goals, etc,
Please share a synopsis of your organization/project's PAT equity and access efforts specific to marginalized communities.
*
Which psychedelic(s) does your organization work with or intend to work with? *
Required
Which kind(s) of legal jurisdiction does your organization administer psychedelics treatment? Please check all that apply.  *
Required
Please list the other psychedelics your organization works with or intends to work with below
What locational impact does your project have? *
Name of city *
Exact name of city, county, state, etc,. Mark N/A as needed. 
Name of county *
Exact name of city, county, state, etc,. Mark N/A as needed. 
Name of state *
Exact name of city, county, state, etc,. Mark N/A as needed. 
Number of people impacted annually.
Organization type
 *
Please share what other organizational type below.
Solutions 
 *
Please check all the equity and access solution types your organization/project is offering in the field of psychedelic assisted therapy,
Required
Please list all other solutions types your work is offering 
Organizational/Project Status
 *
Additional Information *
Please share with us any additional information you'd like to share.
Do we have permission to share this information with the public? *
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