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Intake form

By filling this form out you express your interest in participating in psychedelic therapy. This is a no obligation form. After receival I will asses it and get back to you by email in order to discuss the next step. I am looking forward working with you.

Name *

Email address *

Telefon number *

City of residence *

Age *

What do you expect from psychedelic therapy? *

Are you on any medication, if yes, which one(s)? *

Do you use recrational drogs? If so, which ones? *

Have you used drugs in the past? If so, which ones? *

Have you been diagnosed with mental illness(es)? If yes, please name it. *

Do you have any chronic diseas(es)? (eg. heart, kidney, liver or vascoular problem) *

If there is anything else important you want to let me know in advance, please indicate here. *

Neurotransmitter test *

I often feel emotionally numb or disconnected.
I find it difficult to process or express emotions.
I have suicidal thought.
I had a psychosis.
I frequently experience intense mood swings.
I have recurring intrusive or obsessive thoughts.
I have a hard time focusing or concentrating for extended periods.
I feel overwhelmed by anxiety or dread without a clear cause.
I have a persistent sense of hopelessness.
I find it hard to trust people, even close friends or family.
I experience frequent feelings of shame or self-blame.
I often feel disconnected from reality (e.g., dissociation, depersonalization).
I isolate myself or avoid social contact most of the time.
I struggle with maintaining personal relationships.
I engage in compulsive or impulsive behaviors.
I have a history of self-harm or suicidal behavior.
I often feel like I'm living on 'autopilot.'
I have a tendency to avoid painful memories or emotions.
I have frequent nightmares or sleep disturbances.
I am easily startled or hyper-alert.
I find myself reliving past traumatic experiences.
I feel like I'm stuck and unable to grow emotionally.
I have been diagnosed with depression, anxiety, PTSD, or another mental health condition.
I have experienced a psychotic episode.
I have been hospitalized for mental health reasons.
I have attempted suicide in the past.
I have a family history of bipolar disorder or schizophrenia.
I currently take psychiatric medication.
I've been in therapy or counseling before.
I currently see a mental health professional.
I've been told I may have unresolved trauma.
I have used psychedelics in the past and had a negative experience.
I understand the risks and benefits of psychedelic therapy.
I have clear intentions for participating in psilocybin therapy.
I feel emotionally safe and supported in my current life.
I am currently in a stable mental and emotional state.
I have a trusted support system I can rely on after my session.
I am open to exploring difficult or repressed memories.
I am willing to engage in preparation and integration work.
I believe this therapy could help me grow or heal.
I do not currently feel coerced or pressured to do this therapy.
I am ready to commit to this journey with sincerity and self-responsibility

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