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1. Age at time of trip (Required.)

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2. Drug(s) taken (Required.)

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3. Amount taken (actual measurement and/or # of doses): (Required.)

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4. Surroundings (setting, location, who were you with, atmosphere)
 (Required.)

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5. Trip details (please include: physical details, mental details, emotional details & anything else you'd like to add) (Required.)

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6. What was good about your trip? (Required.)

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7. What didn't you like about your trip? (Required.)

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8. How did you deal with the negative aspects? What worked? What didn't? (Required.)

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9. What did you learn about dealing with bad trips? What will you do next time (before, during, or after your trip)? (Required.)

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10. What advice would you give someone else about dealing with a bad trip? (Required.)

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