Confirm Eligibility

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

Yes

No

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

Yes

No

Do you have any heart conditions? Epilepsy? Aneurysm in the past? *

Yes

No

Have you ever been diagnosed with schizophrenia, bipolar disorder, or a personality disorder such as borderline or narcissistic? *

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

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

Yes

No