Safe Space Intake Form Intake form: Name(required) Email(required) (Mobile) phone number plus country code(required) Where do you live? How old are you?(required) Have you ever had any experience with psychedelics (e.g. Psilocybin, LSD, MDMA, DMT, Ayahuasca, Ketamine, erc.)?(required) Yes No Have you or any relatives suffered from any mental health issue or did you (and/or your child) suffer possible psychological trauma?(required) No Yes Not sure If so, or unsure, which mental health issues does it concern? Please elaborate. Are you using any type of medication? Please list them here: When would you like to have a session? What date? Message / Questions Submit Also, please sign the the terms & conditions, here.