Consultation Survey

Please fill out the information below to the best of your ability. After completing the survey, you will receive a link to book your complimentary consultation with one of our practitioners. The link will pop up once you submit your information, as well as via email and sms. We look forward to co-piloting this journey with you!

General Section

Somatic : The Body

Psycho-Emotional : The Heart

Cognitive : The Mind

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2. Email

1. Full Name

3. Gender

Female

Male

Other

Prefer not to share

4. State

5. Age

7. Height (ft / inches)

6. Weight

8. Are you currently working with a Mycology Psychology Practitioner?

Yes

If yes, who are you working with?

12. Tell us about your employment. Check all that apply.

Full Time

Part Time

Self Employed

Multiple positions

Volunteer

Business Owner

Freelance

Unemployed

13. What is your main motivation / intention for starting this treatment?

14. Additional information (Please share any details that can help us understand your current life situation and your personal process to better support you).

15. Have you had experiences with sacred plants and alternative medicines? Please specify.

16. Generally, what is your level of tolerance to most substances (including caffeine, alcohol, plant medicines, etc.)?

Very High

High

Average

Very low

17. We highly recommend therapeutic support as microdosing is dramatically enhanced by integration. We offer 15 min сheck-ins and full sessions. Check all that apply.

Yes. I'm interested in check-ins.

Yes. I'm interested in hourly therapeutic sessions.

No thank you.

9. How did you hear about us?

Instagram

Google search

Direct Referral (referred by:)

10. Phone number

11. Occupation

*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

Policy

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