Plant medicine is a tool for healing and the work comes after when integration occurs. The clinician providing space vehemently disclaim any liability, loss, injury, or damage, from the use of plant medicines, or from your informed decision to partake in the activities and services provided by the clinician.

Range of possible subjective and experiential effects that may occur during medicine administration, which may include: -Changes in perception -Changes in sense of time and/or space -Various emotional and/or behavioral responses -Mystical-type effects, including a sense of unity, sacredness, and deeply felt positive mood. Psilocybin is exceptionally safe. However, some common side effects during psilocybin journey may include: -Challenging emotional (e.g., fear and sadness) and physical (e.g., body shaking or trembling) experiences -Transient fear, anxiety, and/or grief -Increase in heart rate and blood pressure -Confusion or paranoia -Restlessness -Headache - Nausea/vomiting -Dizziness.

By submitting this form, I agree that:

1. I have fully read this informed consent from describing the use of Psilocybin Therapy

2. I fully understand that the psilocybin sessions can result in a profound change in mental state and may result in unusual psychological and physiological effects.

3. I understand the risks and benefits, and I freely give my consent to participate in Psychedelic Assisted Psychotherapy (PAT) as outlined in this form, and under the conditions indicated within.

4. I declare that I do not have any of the medical exclusions: uncontrolled hypertension, congestive heart failure, impaired cardiac status, COPD, severe obesity, kidney disease, liver disease, allergy to psilocybin, pregnancy.

5. I declare that I do not have any of the psychiatric exclusions: any mania, schizophrenia, schizoaffective disorder, significant dissociative disorder, alcohol/substance abuse or severe personality disorder.

6. I understand that the provider signing this form has the right to discontinue treatment at any time for concerns regarding medical/psychiatric health, or no perceived benefit.

REGISTRATION FORM