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Private Journey Intake Form
Email address *
Name *
Your answer
Emergency Contact *
Your answer
Please describe your intentions for wanting to do this work? It can be one sentence to one page. No need to get “hung up” on this if it’s not fully realized. *
Your answer
Please tell me the last time you took more than a micro-dose of any psychedelic medicine.
Your answer
Do you have any fears of the psychedelic landscape? *
Your answer
Describe your profession in no more than two paragraphs. *
Your answer
Are you currently in a romantic relationship? If so, does your partner support you doing this type of healing work? *
Your answer
Describe, if any, trauma that you might have as a result of emotional or physical injuries? *
Your answer
Please list any and all medications that you are currently taking. This included recreational cannabis. *
Your answer
A copy of your responses will be emailed to the address you provided.
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