The Psilocybin Facilitator Program Health Questionnaire

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* 1. I  accept that all data provided on my Health Screening Questionnaire may be stored, processed, and analyzed by The Leela School for the purpose of eligibility to partake in psychedelics.  The Leela School strongly suggest you consult with your health care provider prior to applying for psychedelic retreats using psilocybin.  The Leela School is not a health care provider and does not treat mental or physical disorders.  All information collected is stored in a HIPAA compliant manner and will not be shared except with the two members of the health review group including Dr. Bonny Koeber, and Dr. Casey Frieder.

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* 2. What is your full name?

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* 3. What is the date of your birth?

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* 4. At what email address would you like to be contacted?

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* 5. What is your gender?

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* 6. What is your mailing address?

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* 7. What is your profession or what do you primarily do?

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* 8. Do you have a history of, or have you been diagnosed with any of the following psychiatric disorders?

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* 9. Have you recently (within the last 6 weeks) taken lithium?

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* 10. Have you been diagnosed with a neurological disorder? (Examples include brain tumor, pituitary disorder, epilepsy, dementia, ALS, Parkinson’s disease, or multiple sclerosis)?

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* 11. If you answered yes to the above question, please explain in the space below.

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* 12. Have you ever or do you currently suffer from any of the medical problems listed below?

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* 13. Have you been diagnosed with Insulin Dependent Diabetes?

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* 14. Do you currently suffer from liver/hepatic impairment?

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* 15. If you answered yes to the above question, please explain.

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* 16. Do you currently suffer from renal/kidney problems?

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* 17. If you answered yes to the above question, please explain

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* 18. Have you ever used psychedelics?  Please note that experience with psychedelics is not required to participate in psychedelic supported retreat.

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* 19. Which psychedelics have you used before?

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* 20. What settings have you previously used psychedelics in?

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* 21. How many times have you previously used psychedelics (excluding microdosing)

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* 22. Have you ever had a challenging psychedelic experience that resulted in a difficult integration period and negatively impacted your life?

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* 23. If you answered yes to the above questions, please explain.

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* 24. Individuals with certain psychiatric conditions may have increased risk of adverse psychological reactions when consuming psilocybin. These risks have not been extensively studied or quantified. Studies have generally excluded individuals at high risk for adverse events and negative outcomes such as patient with a history of psychosis, bipolar disorder, or a family history of these conditions. Your psychological health is a crucial factor for the safe consumption of psilocybin. The use of psilocybin is weakly associated with triggering psychotic like symptoms. Disassociation to a large extent is explained by the presence of other psychiatric disorders and/ or the use of other Psychoactive substances.

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* 25. We at the Leela School are not engaged in medically treating psychological disorders.  Consuming psilocybin could possibly present additional risks for individuals experiencing thoughts related to self harm or suicide.  Have you ever been diagnosed with or have you ever suspected that you suffer from Depression?

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* 26. If you answered yes to the above question, would you mind explaining further how depression has affected your life?

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* 27. Have you ever been diagnosed with any form of Post Traumatic Stress Disorder (PTSD) or ever suspected that you suffer from trauma?

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* 28. If you answered yes to the question about PTSD would you please elaborate?

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* 29. Have you ever been diagnosed with, or have you suspected that you suffer from Addiction or substance abuse disorder?

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* 30. If you answered yes to the  question on substance abuse, would you please elaborate?

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* 31. Do you have or have you suffered from chronic pain?

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* 32. If you answered yes to the question about chronic pain, would you elaborate?

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* 33. Would you be able to lie down for several hours during a psychedelic supported ceremony?

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* 34. Have you ever attempted to take your own life?

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* 35. If you answered yes to the above question, would you please elaborate?  

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* 36. Have you ever been hospitalized for psychiatric reasons?

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* 37. If you answered yes to the question above, would you please elaborate?

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* 38. Are you currently receiving mental health care services from a provider (psychiatrist, psychologist, therapist, counselor, or non-traditional provider?

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* 39. If you answered yes to the above question, would you please provide their contact information?  Also, are they aware of your plan to use psilocybin?

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* 40. Please rate your level of agreement with the following statement:  If I were struggling physically, mentally, or emotionally  after the use of psilocybin, I would feel comfortable seeking the help and support of a mental health provider.  

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* 41. Do any of your relatives suffer from a mental disorder?

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* 42. If you answered yes to the question above, which relatives have a diagnosis of a mental disorder?

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* 43. Have you experienced any form of sexual abuse or other types of trauma?

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* 44. If you answered yes to the above question, would you care to elaborate?

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* 45. Please rate your level of agreement with the following statement. I have emotionally processed traumatic experiences in my life, and they no longer impact my day to day life in a negative way.

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* 46. The use of psilocybin can lead to transient adverse physical effects.  The higher the dose, the more common and intense the effect.  Additionally, the effects can vary depending on a person’s genetic background, the use of certain medications, and the presence of certain physical conditions.
Cardiovascular:  Psilocybin may cause transient increases in your heart rate and blood pressure.  Psilocybin can cause adverse changes in your heart rhythm.  Using psilocybin can be dangerous in people with cardiovascular conditions.
Gastrointestinal: Psilocybin can cause transient nausea and vomiting
Hepatic:  Psilocybin is broken down to its active ingredient in the liver.  Taking psilocybin in the presence of liver impairment can be dangerous and influence the duration and intensity of the effects.
Renal:  Psilocybin is eliminated from the body by your kidneys. The ingestion of psilocybin in people with kidney disease can be dangerous and may result in injury.

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* 47. What is your current height in inches or in cm. ( Please write the measurement after the number.)

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* 48. What is your current weight in pounds or kg. (Please write the measurement form after the number)

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* 49. Are you independent with your daily living activities?

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* 50. If you answered no to the above question, would you explain what you require in order to accomplish you daily living activities?

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* 51. Are you pregnant, planning to become pregnant, and/or breastfeeding?

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* 52. Can you elaborate on any health condition which you stated that you suffer from?  Current condition, complications, etc?

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* 53. Can you walk up one flight of stairs without stopping?

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* 54. There has been much research done on certain medications and psilocybin being taken at the same time.  Many medications  can be dangerous when combined with psilocybin.  This is particularly true of  medications used to treat depression, anxiety, mania, seizures, psychosis, bi-polar disorders, schizophrenia, schizoaffective disorder, and hypertension.  Please list all current prescribed medications and all unprescribed medications that you take.  If you do not take any medication list none.

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* 55. Are you currently taking any supplements or herbal medications (Ashwagandha, 5-HTP, St. John’s wort?

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* 56. I would experience unpleasant physical, behavioral, or emotional reactions if I were to stop taking Alcohol, Benzodiazepines (Valium, Ativan, Xanax)

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* 57. Do you feel you are ready to meet physically, emotionally, and mentally any challenges that may surface during a psychedelic experience?

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* 58. If you answered no to the above question, would you please elaborate?

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* 59. If you were uncomfortable  or struggling during a psychedelic experience, would you be able to ask for assistance ?

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* 60. Is your support circle (family, friends, etc.) aware of your intention to participate in a psychedelic supported retreat?

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* 61. Will your family or support circle (family, friends, etc.) be supportive in your psychedelic supported retreat?

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* 62. What is the name and contact number of a person you would like us to contact in case of an emergency.

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* 63. What is your intention for participating in The Leela School Psilocybin Facilitator program?  What challenges do you hope to overcome?

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* 64. Is there anything else pertaining to your physical, emotional, or mental health that you would like to share with our Health Screening Team?

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* 65. Do you have any food or drug allergies?

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* 66. Do you have any dietary restrictions or requirements?

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