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Name(Required)

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Email(Required)

Phone(Required)

Age(Required)

Have you ever used ketamine before?(Required)

Yes

No

Have you ever used other psychedelics (eg. LSD, Psilocybin, DMT, Ayahuasca, MDMA) before?(Required)

Yes

No

Which other psychedelics have you tried before?(Required)

Do you have any medical conditions?(Required)

Do you have a history of any major mental health diagnoses?(Required)

Major Depressive Disorder

Generalized Anxiety Disorder

Bipolar Disorder

Schizophrenia or Schizoaffective Disorder

Episode of psychosis

Other

If you selected other in the previous question, please specify here(Required)

Do you take any medications or supplements?(Required)

What about this program interests you?(Required)