Name *

First Name

Last Name

Phone

(###)

###

####

Are you over the age of 21? *

Yes

No

Have you taken any form of Lithium in the last 30 days? *

Yes

No

Have you ever been diagnosed with psychosis or treated for active psychosis? (Or have a close family member who was diagnosed with such condition) *

Yes

No

Do you have any major medical conditions? (i.e. heart disease, seizures, aneurysm, stroke) *

Yes

No

Have you ever been diagnosed with schizophrenia, bipolar disorder, mania, or a personality disorder? *

Yes

No

Do you have a history of violence or angry outbursts? *

Yes

No

Are you having thoughts of causing harm, or wanting to cause harm, to self or others? *

Yes

No

Have you ever had an allergic reaction to consuming mushrooms or other fungi? *

Yes

No

Are you experiencing any substance use or addiction challenges? *

Yes

No

Are you currently pregnant or breastfeeding? *

Yes

No

Can your life accommodate some instability at this time? *

Yes

No, but I would still like to learn more

Do you currently have supportive community? (i.e. supportive family, friends, partners, groups) *

Yes

No, but I would still like to learn more