Psychedelic Coaching: New Client Intake Form

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First Name *

Email *

What's your instagram handle?

What's your timezone? *

Are you over 21 years old? *

Yes

How did you hear about my coaching? *

Are you currently taking SSRI medications? *

Yes

Prefer not to answer

Do you have any history of schizophrenia or bipolarism? *

Yes

Prefer not to answer

What are you grateful for today? *

Why do you want to work with me privately? How do you know I'm the right coach for you? *

What are your biggest struggles right now in business/life? *

What are your biggest goals? *

What have you currently been doing to reach those goals? *

In which of the following would you like more help? *

Microdosing

Shadow Work

Setting Boundaries

Other:

Required

Have you made the necessary financial assessment and are you in a position to invest? The investment is about 997$. *

Yes

Do you have any reservations about hiring me as your microdosing coach? *

If you would be selected, could you download the app Signal so that we can talk safely? *

Yes

What's your phone number? *

Any other comments:

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