Screening Questionnaire for Psychedelic Integration TreatmentS

Step 1 of 13

Completion Time Advisory: Please note, this form may take up to 30 to 45 minutes to complete. We recommend filling out this screening questionnaire at your own pace. Your information will only be submitted after clicking the final submission button. Please note that refreshing the page may result in losing the information you've entered in the form.

Segment 1: Client Information

1.1 Personal Information

(to determine the dosage of Psilocybin)
(to determine the dosage of Psilocybin)

Emergency contact details in case of a medical emergency, psychiatric needs, or other urgent concerns. By filling out the emergency contact details, you provide us permission to contact this person accordingly if necessary.

Scroll to Top