Intake Form Psilocybin Journey

Soon you will be taking part in a (private or group) psychedelic ceremony with psilocybin truffles, which are generally considered to be extremely safe and are 100% legal here in the Netherlands.

Nonetheless, a ceremony like the one you will be attending comes with risks. It could bring up feelings of fear, anger, frustration, confusion or other negative psychological effects, and in exceptional cases can lead to psychosis or schizophrenia. The use of psychedelic substances (and therefore joining this ceremony) is in all cases entirely at your own risk. The ceremony organiser, ceremony holder, affiliated partners and companies can in no way be held liable for the consequences of joining this ceremony.

If you wish to partake, please first read the information below and fill in this form carefully so that you are well informed.

Contraindications

Below you will find a list of general contraindications for psychedelic medicine work. Due to privacy rules, I cannot ask you to share your medical history/file with me. For your own safety, the safety of your fellow participants and for myself, it is of utmost importance that you are aware of your responsibility to take these contraindications seriously and consult with me about your participation if there is anything on this list that applies or might apply to you.

The ceremony should not be joined in the following cases (participant has the right to request a refund):

In case of any questions or unclarity, please make sure to contact me. Please also fill in your personal details and answer the following questions below – if you have to answer “no” to any of these questions, please contact me first.

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Name *

First

Last

Email *

Phone

Date of birth

Address

ZIP code

Country

Emergency Contact (name & phone number):

Have you ever attended a Psychedelic Medicine Ceremony before? If yes, please mention which medicines you've worked with and specify briefly.

What is your intention for joining this ceremony?

I understand that this statement is binding as a contract, is not for informational purposes only, and I declare that I have signed this document out of my own free will.

• Yes

I declare that I am able to look at myself, to take responsibility for my own choices, interpretations and (mental) processes.

• Yes

I declare that I am not pregnant or breastfeeding at this time.

• Yes

I declare that I am not currently being treated by a physician, psychiatrist, or psychologist, or have been treated for addiction, schizophrenia, or other psychological disorders.

• Yes

I declare that I am in good health and currently not on any (prescription) medication.

• Yes

I understand that there are risks involved in attending this ceremony and I am aware of the contraindications.

• Yes

I am aware of the risks involved in attending this ceremony and of the contraindications.

• Yes

Is there anything else I need to know before working with you?

Send