Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

1. Are you pregnant or nursing? [Answering yes to this question requires postponing your session until you are no longer pregnant or nursing.] *

Yes

No

2. Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this event? [A TCE/CCC is not appropriate for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy.] *

Yes

No

3. Have you ever (been diagnosed with) required significant treatment or been hospitalized for a psychological or emotional disorder, or for any other psychological or emotional reason? Mental Health Contraindications (reasons not to attend) include but are not limited to clinically significant acute anxiety or other severe mood disorders, psychosis, bipolar disorders, personality disorders, acute/unprocessed trauma and PTSD (without support), acute addictions, suicidal ideation/self harm and tendencies for disruptive behavior.] *

Yes

No

4. Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically, emotionally or otherwise? *

Yes

No

5. Has a health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or using altered states practices? *

Yes

No

6. Have you ever experienced extreme paranoia or anxiety, panic attacks, or other extreme negative experiences while using cannabis, or any psychedelic drugs, or during any other times in your life that a significant intervention? [We’ve all experienced anxiety in one form or another... the key here is something that required a significant intervention.] *

Yes

No

7. Have you ever dealt with a pattern of unstable relationships that caused you significant distress? *

Yes

No

8. Have you ever fainted or blacked out or otherwise adversely lost consciousness while on cannabis or any psychedelic medicine? [While this can happen to anyone, some are more susceptible than others, particularly those with low blood pressure. Please let a facilitator know and take extra time in sitting and standing up after the completion of a TCE/CCC.] *

Yes

No

9. Have you ever had extremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep for days or racing thoughts, or alternatively extremely low energy) after the effects of a psychedelic/cannabis should have worn off? [These could be symptoms of certain mental health concerns that should be evaluated by a mental health professional.] *

Yes

No

10. Have you ever seen or heard things or people that weren’t there after the effects of a psychedelic or cannabis should have worn off? *

Yes

No

11. Have you ever obsessed over an idea or belief in a way that has caused difficulties in your life? *

Yes

No

12. Do you have any acute, current or past substance abuse/dependence issues? [While cannabis can be used to treat addiction, addiction treatment requires additional support.] *

Yes

No

13. Are you currently on any medications, supplements or recreational drugs that could affect you safely participating in aTCE/CCC? [Using other mind-altering substances besides cannabis in a TCE is expressly forbidden. Please do not come on any other mind-altering substance as it would increase the likelihood of a difficult or overwhelming experience and negatively affects the safety of yourself and other participants.] *

Yes

No

14. Do you have a history of disruptive or violent behavior, either physical or emotional? [For the safety of our participants, any intentionally disruptive behavior is not tolerated at aTCE/CCC. Disruptive behavior does not include spontaneous healing and transformational releases that require Facilitator intervention and support.] *

Yes

No

15. Do you have a history of traumatic or difficult life events that has not been addressed or is not being supported therapeutically? [TCEs/CCCs are designed to compliment psychotherapy, not replace it. If a difficult past experience unexpectedly comes up in your experience during a TCE, you are strongly encouraged to seek professional mental health support.] *

Yes

No

16. Do you have any present concerns around suicide or self-harm? [Again, a TCE/ CCC is not the appropriate context to address suicidality or self-harm without significant psychological support. Please seek professional mental health support.] *

Yes

No

17. As you contemplate attending this experience, or when checking in with yourself right before it begins, are you extremely anxious? [While mild to moderate anxiety is completely normal before a TCE / CCC, extreme anxiety, panic, and physically shaking/trembling before an experience is an indication to maybe not participate or check in with the facilitator.] *

Yes

No

18. Have you recently had a major transformational experience, with a psychedelic medicine or otherwise, that feels almost complete but not quite, or unresolved? [Ask us about this one if answering yes. It has been our experience that people who have done a lot of transformational work can have significant breakthrough experiences in a TCE/CCC. This is good news but can be intense. Please prepare accordingly.] *

Yes

No

19. Do you ever feel extremely uncomfortable in group transformational processes? [Even though you will be safe and fully supported in the TCE/CCC, it is still a deeply transformational process in a group setting (unless an individual experience). Previous experiences in group processes is an indication of how comfortable you’ll feel in a TCE/CCC]. ** Not applicable to individual one on one sessions/ experiences. *

Yes

No

20. Are you currently employed, a student, or otherwise financially stable? *

Yes

No

21. Do you have a safe home environment and a stable residence? *

Yes

No

22. Are you currently involved in any legal proceedings? Criminal or civil? [Please speak to the facilitator before attending to ensure this is a safe experience for you, i.e. probation requirements.] *

Yes

No

Date *

MM

DD

YYYY

Please check the box below. *

By checking this box, I have read and agree to the agreement below. All information provided is accurate and true according to my knowledge.