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Consultation Survey

General Information

Gender
How sensitive are you to substances such as coffee, alcohol, drugs?
What is your level of stress?LowLowMediumMediumVery HighWhat is your level of stress?

Psycho - Emotional Area

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What is your level of stress?

Low

Medium

Very High

Do you feel anxiety?NeverNeverSome TimesSome TimesVery OftenDo you feel anxiety?

Do you feel anxiety?

Never

Some Times

Very Often

Do you feel depressed?

Never

Some Times

Very Often

Do you feel depressed?NeverNeverSome TimesSome TimesVery OftenDo you feel depressed?

How would you evaluate your emotional health?

Poor

Average

Very good

How would you evaluate your emotional health?PoorPoorAverageAverageVery goodHow would you evaluate your emotional health?
Do you have any addiction?
Do you have any psychological disorder? Check all that apply.

Well - Being

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How is the quality of your focus and attention?PoorPoorAverageAveragevery GoodHow is the quality of your focus and attention?

How is the quality of your focus and attention?

Poor

Average

Very Good

How is your level of energy/stamina during the day?Very LowVery LowVariableVariableVery Good and StableHow is your level of energy/stamina during the day?

How is your level of energy/stamina during the day?

very low

Variable

Very Good and Stable

How is the quality of your sex drive and Libido?

very low

Regular

Very Satisfactory

How is the quality of your sex drive and Libido?Very LowVery Lowregularregularvery satisfactoryHow is the quality of your sex drive and Libido?
How is the quality of your sleep/rest?
What kind of diet do you have? Check all that apply.

Motivation

We highly recommend therapeutic support as microdosing is dramatically enhanced by integration. We offer 15 min check ins and full sessions.

Best contact number*

I would like to be contacted on:
Mycology psychology values curiosity. We are currently collecting feedback to help us all deepen our understanding of emerging patterns in these treatment methods. Check here if you’d like to participate in this cutting edge research.

Thanks for submitting!

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