Therapeutic Eligibility Form

Name:


Email:


Country code + phone:


Age:


Date of Birth:


Occupation:


Are you currently undergoing psychiatric treatment with controlled medications?
E.g., Antidepressants, anxiolytics, antipsychotics:

Please mention your treatment. It is important for us to know about your treatments, as your health is our top priority, and we aim to tailor options to suit your needs.

If you answered Yes to the previous question,
what medications are you currently using?


Do you or any of your first-degree relatives,
e.g., parents or siblings, suffer or have suffered from psychosis, mania, or bipolar disorder?


Do you currently have any issues with substance use?
E.g., alcohol, tobacco, cannabis, controlled psychiatric medications, psychedelics?


If you answered Yes to the previous question,
please specify which substances you are currently having issues with.


Currently or in the past three months,
have you had thoughts of ending your life or have you attempted to do so?

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