Psychedelic Assisted Therapy Interest Form

First Name *

Last Name *

Phone number *

Email *

Birth date *

Thank you for your interest. We'd like to hear a bit more about your availability and interest in psychedelic harm-reduction therapy.

What day(s) of the week is it easier for you to come for an appointment? *

Please answer this question.

What time of the day is usually better for you? *

Please answer this question.

What is the reason of your interest in psychedelics? *

Is there anything else you would like to share or make sure we are aware of? (optional)