Psychedelics Form / Forme psychédélique
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Consent Form/formulaire de consent 
Please note, this study is completely anonymous and all information is protected
Study Description
  • Active Military Members (Canadian Forces Personnel) are NOT eligible to participate
  • We are conducting a study to see the impact of your non-recreational experience with various psychedelic medicines for wellness which includes your mood, function and quality of life
  • The data on the use of psychedelic medicines for therapy is still new. By understanding your experience we can better understand why you used it, how much it helped and where it impacted your wellbeing.
  • The medicines of interest include: 
  • Psilocybin (Magic Mushrooms), 3,4-Methylenedioxymethamphetamine (MDMA), N,N-Dimethyltryptamine  (DMT, Ayahuasca), Lysergic Acid Diethylamide (LSD),  Ibogaine and Ketamine
  • Through questionnaires we will collect data on your last use of these substances, your pain, mood, function and the impact of the psychedelic medicines .
  • This data will also include information about past your medical history, your occupation, and medicine related side effects
  • We understand these medicines are currently considered illegal in many places
  • Therefore participation in this study is anonymous and therefore you cannot be identified in any way
  • After the study is complete, we will analyze how much these medicines  helped
I have read the instructions and understand that I may obtain additional information by contacting
  • Study participation may be up to 1 hours
  • If accepted into the trial we will provide the materials to you directly via mail or email link
  • I am free to refuse to participate in this study and may withdraw my consent without prejudice or hard feelings at any time before, during, or after the study.
  • My participation in this research project will cease immediately, as soon as the investigators deem it safe to do so
  • Investigator(s), or their designate, may terminate my participation at any time, regardless of my wishes.
  • For survey questions, I can decline to answer any questions without providing any explanation or justification.
Potential Incentives - none

  • The risks associated with this research protocol are acceptable.
  • Worsening mood and anxiety after answering the survey questions – Please ask for supportive care as required
  • In case of an event or injury please notify a team member immediately to receive the appropriate care
  • In the unlikely event that you become incapacitated
  • Investigator(s) will seek immediate medical attention
  • Every effort will be made to contact a family member or the designated person
  • “Incidental findings” is a term that describes unanticipated discoveries made in the course of research. Should an incidental medical finding be detected by qualified personnel, you will be notified of that finding and be advised to seek appropriate medical follow-up. Incidental findings or potential injuries occurring during the course of participation.
  • Information and data collected from me will be kept confidential
  • This data will not include any personal or identifying information.
  • I will be assigned a unique identification number (alphanumeric code). All electronic data will be stored on the investigators; work computers, which are password protected
  • My data will be protected according to existing healthcare guidelines and not revealed to anyone other than the Investigator(s) without my consent except as data unidentified as to the source
  • Any hard copy data will be stored in locked cabinets and only the investigators will have access to these files
  • My name will not be:
  • a. identified or attached in any manner to any publication arising from this study
  • b. anywhere in the data files, other than this consent form
  • Experimental data may be reviewed by an internal or external audit committee but any summary information resulting from such a review will not identify me personally.
  • You can request a copy of any published research by emailing with request to be emailed a copy upon completion.
Government Policies
  • Researchers are committed to protecting my personal information
  • However, under the Access to Information Act, copies of research reports and research data (including the database pertaining to this project) held in Federal government files, may be disclosed.
  • Prior to releasing the requested information, the Directorate of Access to Information and Privacy (DAIP) screens the data in accordance with the Privacy Act in order to ensure that individual identities (including indirect identification due to the collection of a combination of unique identifiers such sex, age, occupation)are not disclosed.
Contact information
  • For any questions or concern regarding this project before, during, or after participation, please contact any of the below
  • Investigator:
  • Chair, DRDC Human Research Ethics Committee, email: ; (416) 635-2000, ext. 3141. 1133 Sheppard Avenue West Toronto, Ontario, M3K 2C9I hereby volunteer to be a participant in this study.
I understand that by agreeing to this consent form I have not waived any legal rights I may have as a result of any harm to me occasioned by my participation in this research project beyond the risks I have assumed. Also, I understand that upon request I will be given a copy of this consent form so that I may contact any of the above-mentioned individuals at any time in the future should I wish.
Consent -- I AGREE.... *
Date *
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