1. Application form VistaPlus+
This registration form helps to determine if applicants are suitable to join our guided psychedelic programs. After applying we will contact you for a personal intake call (15-30 min.)

Disclaimer: Experimenting with psychedelics is always at your own risk. Always consult a doctor if you intend to start using psychedelics in combination with other medication.

By completing this form you clearly state that you have read and understood our disclaimer.
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Email *
First name *
Last name *
Street and house number *
ZIP code and address *
What is your phone number? *
Male/Female *
What nationality do you have? *
Date of birth
MM
/
DD
/
YYYY
For which program(s) would you like to apply? *
Required
Do you work and / or study? *
Family history of psychosis? *
Family history of schizophrenia? *
Are you currently taking antidepressants? *
Do you use medication? *
If yes, what kind?
Would you say that you suffer from ... *
Required
Would you say that you are addicted to ... *
Required
Have you used psychedelics before? *
If so, what psychedelics have you tried before? *
Required
Have you microdosed before? *
If yes, with what substance?
How did you hear about VistaPlus+ ? *
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The following section of this questionnaire helps with creating a baseline of your physical-, emotional- and mental state of being.
On a scale of 1 to 5, are you happy? *
Not so
Very
On a scale of 1 to 5, are you insecure? *
Yes
No
On a scale of 1 to 5, are you restless? *
Yes
No
On a scale of 1 to 5, how much energy do you have? *
Little
Lots
On a scale of 1 to 5, how is your libido? *
Low
High
On a scale of 1 to 5, do you experience a lot of stress? *
Yes
No
On a scale of 1 to 5, how is your concentration? *
Bad
Good
On a scale of 1 to 5, how creative are you? *
Not
Very
On a scale of 1 to 5, how aware are you of your emotions? *
Not
Very
On a scale of 1 to 5, are you present (mindfull)? *
Not
Very
On a scale of 1 to 5, how is your energy level? *
Low
High
On a scale of 1 to 5, how well are you in touch with your feelings? *
Poorly
Well
On a scale of 1 to 5, how well do you sleep? *
Bad
Good
If you meditate regularly, on a scale of 1 to 5, how is your meditation going?
Poorly
Well
Clear selection
If you have a relationship, on a scale of 1 to 5, how is your relationship?
Bad
Good
Clear selection
What is your intention to explore working with psychedelics? *
I hereby authorize the use of my personal experience data from these surveys with the purpose of supporting research into the therapeutic effects of psychedelics.

You can withdraw your consent to use your personal data at any moment. In that case all personal and research data will be deleted.

 *
Required
When you send this questionnaire you state that you have filled in all the answers truthfully.
Disclaimer: VistaPlus aims to collect data for further research, to facilitate experience, knowledge and information about psychedelics, and to limit any risks. We condemn the purchase, possession, sale and consumption of any form of illegal drugs. Experimenting with psychedelics is always at your own risk. Always consult a doctor if you intend to start using psychedelics in combination with other medication.
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