Coaching Application Request

Which program are you interested in?

One-on-One Consultation - One Session One-on-One Consultation - Two Sessions Ten Week One-on-One Personal Guidance Program

Full Name

Address

City

State

Zip Code

Best phone number for text messages

Date of Birth

Please describe your current life.

What would you say is the primary issue in your life that you would like to see “fixed?”

What have you tried up to this point to fix this?

Are you on medications (either pharmaceuticals or alternative medicine)? If so, please list them.

Is there anything else we should know about your medical history?

In addition to or instead of psilocybin, is there any other medicine you would like to work with?

LSD

How would you like to feel immediately after working with us?

How would you like to feel two years from now?

What in your life presents the biggest challenge for you to get where you want to be?

What type of work do you do?

Is there any other type of medicine you would like to learn about? If so, what is it?

Please read and accept the commitment.

I am 100% committed to working on this life changing process and completing all steps that are in the program and the individually designed process that is created for my healing and transformation.

I understand that nothing in this program is to be taken as medical treatment or medical advice. I agree to discuss my mental and physical health with my healthcare providers.

I understand that communication is vital to our working relationship. If I am accepted. into this program, I agree to return emails, text messages, etc. within 24 hours or less.

If I am accepted into this program, I understand that I will sign a hold harmless agreement as well as a confidentiality agreement.

Coaching Application Request Form

How to Harness The Power of Microdosing

How to Harness The Power of Microdosing - Personal Guidance

Where Else Can You Find Us?

Coaching Application Request Form

How to Harness The Power of Microdosing

How to Harness The Power of Microdosing - Personal Guidance

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