Akasha Intake Form
Akasha requires that all new clients fill out this intake form.  Your information will be kept private and confidential.   
Advisory & Health Disclaimer:
Warning: Keep out of reach of children and pets. Consult a physician if you take antidepressants or other drugs or supplements that interact with, or alter brain chemistry or if you have you been diagnosed with severe anxiety, depression, or any other mental illness. Thoroughly research drug interactions and contraindications for any substance you take. Please use caution. Akasha is not to be held responsible for any adverse effects from the use of the compounds included. These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.  Must be 21 years of age or older.  
Microdosing is NOT recommended for people in the following categories:
Severe PTSD / Severe Trauma 
Personal history of schizophrenia or psychosis 
Suicidal Ideation or attempted suicide in the past 24 months 
Severe Grief 
Somatic illnesses involving the heart, kidneys, or liver 
Currently taking Lithium or Tramadol 
Pregnant or breastfeeding 
Under 21 years-old
I have clearly read and understand the above health disclaimer and microdosing recommendations. *
Are you 21 years of age or older? *
First and Last Name *
Email *
Full Mailing Address *
Phone number
What are your intentions in Microdosing? *
Briefly describe your history and use of psychedelics: *
Do you drink Alcohol? *
If answered YES above, please explain how much and how often you consume alcohol:
Certain prescription medication impacts the ability to experience psilocybin. Please let me know if you take any of the following: *
Have you ever been diagnosed with severe cardiovascular disease (including high blood pressure, heart failure, coronary artery disease, or a history of heart attack or stroke)? *
Are you currently taking prescription medication for a medical diagnosis not listed above? *
If you answered yes above, please explain and list all current prescription medications you take:
Please list any over the counter medications, herbal supplements, vitamins you take:
Have you ever been diagnosed with or experienced any of the following:
Please list any allergies or intolerances you may have:
Do you have a know allergy to any of the following: *
Required
Were you referred by anyone?  If yes, please let us know who referred you,  If not, how did you find out about us?
Would you be interested in sharing a testimonial in exchange for a discount on your next order? *
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