Celestial Journeys

Celestial Journeys Intake Questionnaire
Please read the linked articles and answer the following questions.

Why 5MEO

Forbes Article on Bufo

For the safety of all involved, please answer as honestly and transparently as possible. The more transparent you are in your answers, the better we can cater to your specific circumstances. Rest assured that all correspondence between us is completely confidential. Feel free to contact me directly if you have any questions or concerns.
Name*

First NameLast Name
Gender Assigned at Birth*

MaleFemale
What is your Age?*
Weight*
Height*
Are you Vaccinated?

YesNo
Email Address*
Phone Number*
Emergency Contact and Phone Number*
Please list any medications you are currently taking or if you have a history of taking any antipsychotic medications.*
Please describe your medical history, past and present conditions.*
Please list any allergies you may have.*
What is your experience with psychedelics and plant medicines?*
Please check the following boxes you have or have had a history of any of the following*

Depressive DisorderBipolar Spectrum DisordersAnxiety DisordersPTSDObsessive Compulsive DisordeEating DisordersPsychotic DisordersSubstance Abuse or Addictive DisordersPersonality Disorders (Borderline PD)Act of aggression or violent behaviorNone of the above
If you checked any of the above, please elaborate.
What is your intention with this sacrament?
What is you current experience with spiritual and/or personal development?*
Please lets us know who referred to Celestial Journeys*
I, the signee of this application, take full responsibility for my physical, mental, emotional, spiritual, and financial transactions in the relationship between myself and anyone associated with Celestial Journeys.*

I agree
I understand that those affliated with Celestial Journeys are not medical doctors and cannot diagnose, treat, or cure any disease. I should always consult with my medical doctor before making any changes to my prescription medications, diet, lifestyle or exercise program.*

I understand
By typing in your full name here you are agreeing that all of the above information is true and accurate to your knowledge.*
Should be Empty:

Celestial Journeys Intake Questionnaire