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BUFO / 5-MEO-DMT INITIAL SCREENING FORM

Thank you for your interest in working with us. This brief form helps us understand your background, intentions, and suitability before scheduling a discovery call. All information provided is kept confidential.

Personal Information

Intent & Background

Have you previously engaged in therapy, coaching, spiritual practice, or personal development work?
Yes
No
Have you worked with psychedelics or plant medicines before?
Yes
No
If Yes: Please select all that apply
Psilocybin
Ayahuasca
Iboga
Bufo / 5-MeO-DMT
LSD
MDMA
Ketamine
Other

Mental Health Screening

Have you ever been diagnosed with or experienced any of the following?
Bipolar Disorder
Schizophrenia
Psychosis
Depression
Anxiety or Panic Disorder
PTSD
Suicidal Ideation
None of the Above

Physical Health Screening

Do you currently have, or have you ever had, any of the following?
Heart Disease
High Blood Pressure
Seizure Disorder
Significant Respiratory Condition
Serious Neurological Condition
None of the Above

Medications & Substances

Are you currently taking any prescription medications?
Yes
No
Are you currently taking antidepressants or psychiatric medications?
Yes
No
Do you currently use alcohol, cannabis, or recreational substances?
Yes
No

Readiness

Do you currently have support available to you following a Bufo experience?
Yes
No
Do you currently have support available to you following a Bufo experience?
Yes
No
Are you currently experiencing any major life crisis, instability, or acute emotional distress?
Yes
No

Final Acknowledgement

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