Psychedelic Cannabis request for service

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Request for Psychedelic Cannabis Psychotherapy

Services to begin in Spring 2025

If you are interested in exploring how Psychedelic Cannabis Therapy can support your journey, the first step is to complete our intake and screening process. This ensures that the approach aligns with your needs, goals, and medical history while prioritizing safety and effectiveness.

To begin, please complete the request form below. Once submitted, we will reach out to schedule an initial consultation to discuss your goals and suitability for this therapeutic process. Please note that answering yes or no to any specific questions does not make you eligible or ineligible for this treatment, opportunities to expand on your answers will be available during the intake process.

First Name

Last Name

Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this program? A psychedelic experience is not appropriate for people who are pregnant, have cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy. *

Yes

Have you ever had significant treatment or been hospitalized for a psychological or emotional disorder or for any psychological or emotional reason?

Yes

Do you have any past or present concerns around suicide or self-harm? *

Yes

Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically,emotionally, or otherwise? *

Yes

Has a trusted health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or using altered states practices? *

Yes

Do you have any acute, current or past (within the last 2 years) substance abuse/dependence issues? *

Yes

If you are participating in an in-person experience, do you confirm that you will not be driving after the experience and that you have a ride home? *

Yes

As part of the intake process you will be referred to a medical doctor for an assessment prior to Psychedelic Cannabis Therapy, are you willing to meet with an OHIP covered doctor as part of the process?

Yes

Thanks for submitting!

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