Psilocybin Support Coach Training ApplicationWe welcome all individuals who have a calling to serve earth medicines in a safe and professional setting. Name * First Name Last Name Date of Birth * MM DD YYYY Are you 21 years or older? * Yes No Email * Phone * (###) ### #### City & State * Select * I am female I am male I am non-binary Emergency Contact Name * Emergency Contact Phone Number * Are you currently taking any SSRI's, SNRI's, SDRI's, MAOI's, or any mood altering medications? If yes, please list them below and the purpose of the medication in your regards. * List any prescription medications you are taking or have taken in the past 30 days. * List any non-prescription medications you are taking or have taken within the last 30 days. List any herbs, vitamins, or supplements you are taking or have taken within the last 30 days. * Do you consume alcohol regularly? * Yes No Do you consume THC regularly? * Yes No Are you pregnant or nursing? * Yes No Maybe Do you have a history or diagnosis of seizures or epilepsy? * Yes No Please describe any psychological and/or psychiatric diagnoses you may have received, if any. Have you ever experienced or been diagnosed with any of the following? * Schizophrenia Bipolar Disorder Major Depressive Disorder Generalized Anxiety Disorder Manic Disorder Psychosis Dissociative Identity Disorder Other None If other, please describe: Has any of your family members ever experienced or been diagnosed with the following? * Schizophrenia Bipolar Disorder Major Depressive Disorder Generalized Anxiety Disorder Manic Disorder Psychosis Dissociative Identity Disorder Other None If other, please describe: Do you have a history of heart disease or high blood pressure? * Yes No Are you currently taking any heart medication? * Yes No Are you prone to aggression? * Yes No Have you ever been diagnosed with autism? * Yes No Have you ever attempted suicide or experienced suicidal ideation? * Yes No If yes, please describe: Do you have allergies? * Are you prone to nausea? Yes No Do you have a history of substance abuse? * Yes No If yes, please describe: (type/duration) Have you ever obsessed over an idea, conspiracy, or belief in a way that has caused difficulties in your life? * Yes No If yes, please describe: Please list in detail any past psychedelic use (what, how much, effect, outcome). * Have you ever experienced a "bad trip"? * Yes No If yes, please describe: What are the most stressful or challenging issues you are facing currently? * What are your goals for taking this training program? * Do you have any questions or is there anything else important you think we should know? Payment Options: Please choose the option that works best for you. * Payment in full ($5,000) 50% Deposit of $2,500 + 4 payments of $650 5 payments of $1,000 Referral Code: Thank you! Scholarships available for BIPOC & marginalized groupsPossibility of accommodating alternative payment plan arrangements on a case-by-case basis.
