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Member Questionnaire

Contraindications and Cautions

Because psilocybin is such a powerful substance, you’ll want to understand how it can interact with certain conditions and medications. If you may be impacted by potential contraindications, it’s best to consult with supportive and knowledgeable mental health or medical professionals before proceeding with self administered microdosing.

Select an option
Are you interested in a follow up consultation?
Have you previously used psychedelics or dissociative substances? (Required)
Choose your pizza toppings:
If Yes, which ones?
Have you ever had a "Bad Trip" or traumatic experience on psychedelics?
Is reducing drug, tobacco, or alcohol use a goal for you?
Gender
Do you take antihistamines frequently? (More than twice per week)
Are you allergic to mushrooms, mold, or fungus?
Do you use Cannabis?
Do you use alcohol or street drugs?
How often do you use alcohol or street drugs?
Major health / behavior issues Required

The State recognizes these conditions have positive outcome psilocybin studies or positive user-reported outcomes with psychedelics

Neuropathic or pain conditions- check all that apply
Mixed Outcome Mental / Behavioral Issues Required
Diagnosed by:
What treatment have you had for it?
Do you consider yourself to be in emotional, physical, or mental health crisis?
Are you currently in treatment or counseling for your concerns?
Would you like a referral if No?
Are you currently taking prescription medications?
Do you take SSRIs or Anti-Depressants?
Do you take anti-pyschotics?
Do you take ADHD meds?
Do you take Anxiety meds?
Do you take MAOIs?
Do you take narcotic painkillers?
Do you take nutritional supplements?

The above information is true and correct to the best of my knowledge. I understand that I am personally financially responsible for any balance due. I am at least the age of 21 and I am not currently pregnant. I have reviewed and agree to the Notice of Privacy Practices. I authorize use/release of my health information as required by HCU Mushrooms and their members to provide care and benefits. I agree to join the HCU mailing lists. I have read and signed the HCU Mushrooms Ltd Private Member Associate documents.

Thanks for submitting!

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WEBSITE DISCLAIMER: Our website provides information and resources for educational purposes. It is not intended to provide medical advice or treatment. Please consult a healthcare professional for personalized guidance. All sales transactions will appear as HCU on your billing statement.

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