One step closer to Transformation Name * First Name Last Name Email * Phone * (###) ### #### Age * Gender * Location (City, State) * Occupation * Do you take any medications? Please list medication name, dose, and frequency. * Have you taken the prescription drug lithium in the past 30 days? * No Yes Do you have any previous experiences with psychedelics or altered states of consciousness? If so, please describe. * How did you hear about us? * Friend/Family Referral from provider Instagram YouTube Twitter/X Facebook Google/Search Engine Other Thank you for your application. We will reach out to you via email for next steps!
