Name *

First Name

Last Name

Phone *

(###)

###

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Have you ever experienced plant medicine (mushrooms, ayahuasca, etc)? *

There will be an optional plant medicine ceremony that those selected will be able to participate in. The plant medicine we will be exploring is mushrooms.

Yes

No

If selected, will you be participating in the plant medicine ceremony? *

Yes

No

Please select you current diet *

Select all that apply

Omnivore

Vegetarian

Vegan / Plant-based

Pescatarian

Gluten Intolerance

Dairy Intolerance

Seafood/shellfish allergy

Peanut/nut allergy