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Intake form
Help us serve you better
Name
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Email address
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What is your primary interest in psychedelics?
Please select at least one option.
Therapeutic Use
Research
Education
Personal Development
What mental health challenges are you facing?
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Anxiety
Depression
PTSD
Substance Abuse
How did you hear about us?
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Social Media
Referral
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Event
What type of support are you seeking?
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Consultation
Workshops
Research Collaboration
Educational Resources
Preferred method of communication
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Email
Phone
Video Call
Are you interested in participating in research studies?
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Yes
No
Maybe
Which service or services are you interested in?
Please select at least one option.
Psychedelic therapy sessions
Psychedelic integration coaching
Mental health workshops
Psychedelic research collaboration
Customized mental health solutions
Additional questions or comments
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