Earthlings' Pre-Consultation Questionnaire
Dear fellow earthling,

Thank you for your bravery for being here—at this step of the journey with 5-MeO-DMT. We welcome you to take this space to reflect on why you are here and give us an opportunity to learn more about you and touch base on known health risks and interactions with 5-MeO-DMT.

Once we have had a chance to take in what you have shared, we can then connect in-person or over Zoom to discuss your answers, answer any questions you have for us, and discuss the medicine and our process. Should there be questions that you don't feel comfortable sharing here, we can also discuss them in our consultation. What you share is held in confidence with us.

With love and gratitude,
Sagan and Helena

"The confusion is saying 'I don't know,' but the minute you are quiet, you find out that in truth you do know. For in you, you know." — Ram Dass
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Email *
Name *
Phone number *
Location (e.g. city or town)
Why 5-MeO-DMT?
Why now?
What is your intention for the journey?
Have you experienced any of the following mental or physical health conditions?
Check all that apply.
Cardiovascular issue(s)
Pulmonary issue(s) (e.g. asthma)
High blood pressure
Personality disorder(s)
Bipolar disorder
Depression/overwhelming sadness/grief
Anxiety/panic attacks/phobias
Trauma/abuse (emotional, physical, or sexual)
Post traumatic stress disorder (PTSD)
Chronic pain
Could you elaborate on the physical or mental health condition(s) that you checked above (if applicable)? 
Are you:
Have you ever been hospitalized for a mental health condition? *
What medications, supplements, and herbals do you take? *
Is there anything else you would like us to know about your mental and physical health?
Some substances can have dangerous interactions with 5-MeO-DMT. These include: MAOIs (including but not limited to harmala or Syrian rue, phenelzine, and linezolid), lithium, and 5-HTP. We would also recommend avoiding kambo for several weeks after taking 5-MeO-DMT. *
What are some traumas and triggers that you would like us to be aware of as your facilitators?
Have you ever attempted suicide or intentionally harmed yourself (e.g. cutting, clawing)? If so, could you describe the circumstances and aftermath? *
You are welcome to discuss this with us at the consultation instead if that feels safer or more comfortable.
Have you had a suicide plan in the past six months? *
You are welcome to discuss this with us at the consultation instead if that feels safer or more comfortable.
What is your history with psychedelics?
What are your beliefs about life beyond this physical existence?
Who can you go to for support in times of emotional difficulty? (E.g. partner, a family member, friend, therapist)
We recommend you have a conversation with them about your engagement in this experience if you choose to proceed with it. It can provide foundation for when you share your experience with them after.
We share our space with our cat. If you are allergic to cats, how can you take care of yourself?
We prepare herbal tea and snacks for our journeyers. What are some things that you don't eat or drink?
Emergency contact (name, relationship, and phone number) *
You are also welcome to give them our contact. Sagan can be reached at 778-229-7504 and Helena at 778-855-3233.
How did you find out about us? *
What else would you like to share with us or ask us?
Would you like to be added to our occasional newsletter?
A copy of your responses will be emailed to the address you provided.
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