Intake Form

First Name

Last Name

Name you prefer to be called

Address

Address 2

City

State/ Prov

Country

Phone Number

Birth Date

Gender

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

Mental Health (Please select a box only if you have been diagnosed by a medical professional. Do not self-diagnose)

Generalized Anxiety Social Anxiety Panic Attacks Clinical Depression Bipolar 1 Bipolar 2 Schizophrenia Psychosis Psychotic Episodes Paranoia Personality Disorders Attempted Suicide Suicidal Ideation Self Harming Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Attention Deficit Hyperactivity Disorder (ADHD) Autism Body Dysmorphia Anorexia or Bulimia Gender Dysphoria Depersonalization or Dissociation Alcoholism or Other Drug Addictions None

Do you suspect that you may be suffering from any of the above conditions?

Indicate if you have taken any of the following medications in the last six(6) months

SSRIs: Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro), Fluxoetine (Prozac), Fluvoxamine (Luvox) SPARI: Vibryyd (Vilazodone), Trintellix (Vortioxetine) SNRI: Venlafaxine (Effexor), Duloxetine (Cymbalta), Desvenlafaxine (Pristiq), Levomilnacipran (Fetzima) DNRI: Bupropion (Wellbutrin), Mirtazapine (Remeron) TCA: Amitriptyline (Elavil), Nortriptyline (Pamelor), Clomipramine (Anafranil), Imipramine (Tofranil), Desipramine (Norpramin), Chlorpheniramine, Trazodone (Desyrel), Buspirone (Buspar) MAOIs: Phenelzine (Nardil), Isocarboxazid (Marplan), Tranylcypromine (Parnate), Moclobemide, Selegeline (Emsam) Benzodiazepines: Xanax, Valium, Klonopin, Restoril, Ativan Amphetamines: Adderall, Dexedrine, Desoxyn, Ritalin, Concerta Gabapentinoids Steroids Lithium L-tryptophan Epileptic drugs: depakote, keppra, lamictal, trilpetal, tegretol, gabapentin, lyrica Opiates Other None

If you select "Other"

Other Mental Health Diagnoses

Substance Abuse Rehabilitations

Physical Health

Describe Other Physical Health Conditions (if you checked "Other")

Physical Health Medications

Family Mental Health History

Generalized Anxiety Social Anxiety Panic Attacks Clinical Depression Bipolar 1 Bipolar 2 Schizophrenia Psychosis Psychotic Episodes Paranoia Personality Disorders Attempted Suicide Suicidal Ideation Self Harming Obsessive-Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Attention Deficit Hyperactivity Disorder (ADHD) Autism Anorexia or Bulemia Depersonalization or Dissociation Alcoholism or Other Drug Addictions Other None

Family Mental Health History Details

Please list any other medications not listed before that you are currently taking

Please list any vitamins or supplements you are currently taking

Allergies

Do you have any severe or potentially life-threatening allergies that would require the use of an EpiPen?

Yes No

Health Screeing and Full Disclosure

Check this box if you have read and agree to the Health Screening and Full Disclosure in this intake form. Our retreats and sessions involve the ingestion/utilization of psilocybin mushrooms, we carefully screen each guest for their safety prior to attending a retreat or session. You hereby agree that all information you provide in the application is correct and current and that you have disclosed all physical and psychological conditions and all supplements, natural medicines, and medications (prescription and over-the-counter) that you are taking. If necessary, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. We are not a medical facility, and its owners, staff, employees, and agents are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat diseases or illnesses. Instead, we function as guides and facilitate the effects that psilocybin mushrooms have on people.

Medications Note

Check this box if you have read and understand the Medications Note. Our representatives and facilitators are not licensed to give advice on prescription medications. If you are currently taking medication and decide to discontinue using it, please consult with your doctor before discontinuing any medications. If your doctor approves discontinuing your medications, please follow the weaning process provided to you by your doctor.

Please list any recreational drugs you currently use

Are you currently pregnant?

Yes No

Please list any special requirements for room accessibility (For example: wheelchair, CPAP machine, etc.)

Have you attended a Yoga Psychedelic retreat before?

Have you ever done psychedelics?

How did you find About Us?

Please elaborate further

Terms and Conditions

By checking this box and typing my name in the field below, I attest that I have read and understand all of the above written medical information and have openly disclosed all requested health and medical facts. I attest that the information provided above is true and complete, to the best of my knowledge. I understand that falsifying or omitting any relevant information may be grounds for denying my attendance at the retreat or session for which I am applying or denying me access to psilocybin mushrooms while on the retreat, with or without a refund, at our sole discretion. I hereby waive, release and hold harmless Gabriel Osio , Awareness Lab, or any of its Facilitators from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the retreat. By checking this box and typing my name in the field below, I understand that if I choose to attend a retreat and a session without tapering off my medications that there is a significant chance that my experience with psilocybin mushrooms will be reduced. I also understand that I should not change my use of prescribed psychiatric medications until I have consulted with a licensed medical professional. I agree to review all emails and attachments sent to me by Gabriel Osio or Awareness Lab or any of the facilitators as they will contain important information regarding my scheduled retreat/ session. I also agree that I am submitting this application on my own behalf, that all information included is in regard to my own personal information, and that I am not submitting this application on behalf of anybody else.

Please type your name in CAPITAL letters to show that you understand the above and confirm your selection

Accident and Release of Liability Agreement

I hereby assume all of the risks of participating in any/all activities associated with this event, including by way of example and not limitation, any risks that may arise that are not caused by the direct negligence of the parties to be waived. I certify that I have sufficiently prepared or trained for participation in this activity and have not been advised to not participate by a qualified medical professional. I certify that there are no mental or physical health-related reasons or problems which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
(A) I waive, release, and discharge from any and all liability, including but not limited to, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, the following entities or persons: Gabriel Osio, Awareness Lab, and/or their Facilitators, directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;
(B) Indemnify, hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity. I acknowledge that Gabriel Osio, Awareness Lab, their facilitators, directors, officers, volunteers, representatives, and agents are not responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I acknowledge that this activity may involve a test of a person’s physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants but are also present for employees. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I certify that I have read this document and fully understand its content. I am aware that this is a release of liability and a contract, and I agree to it of my own free will.

Please type your name in CAPITAL letters to show that you understand the above and confirm your selection

Intake Form

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