Kairos Integration Psychedelic Guide Training and Certificate Interest Form

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This form is not intended to be used for a medical or psychological diagnosis, rather to inquire about your reasons for participating in a Program or receiving Services. Thank you for taking this important first step on your journey. Because this is an Experiential training, with the option to participate in a non ordinary state of consciousness, we are asking you to fill out this form to understand your background and intentions.

Email *

Phone Number (Note- all communications should be done via the Signal app) *

To ensure my safety and the safety of all involved, I agree to answer the following questions with the utmost integrity and complete honesty.
*

Agree

Today's Date *

YYYY

Full Name *

Company Name, if Applicable

Birth Date *

YYYY

EMERGENCY CONTACT INFO - Include Name, Address, Relationship to you, email and Mobile Number:

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