Mushroom Event Form | Halyna Healing

MUSROOM CEREMONY HEALTH & SAFETY QUESTIONNAIRE

(Confidential – for facilitator use only)

First name

Last name

Email

Date of birth

Year

Month

Day

GENERAL HEALTH

Do you have any chronic medical conditions? (e.g., heart disease, epilepsy, diabetes, high blood pressure)

No

Yes

If yes, please describe:

Have you ever experienced seizures?

No

Yes

Do you have any allergies (including food, plant, or medication)?

No

Yes

If yes, please describe:

2. MENTAL HEALTH HISTORY:

Have you ever been diagnosed with a mental health condition?

No

Yes

If yes, please describe (e.g., depression, anxiety, bipolar, schizophrenia, PTSD):

Are you currently seeing a therapist, psychiatrist, or other mental health professional?

No

Yes

Have you ever experienced psychosis, hallucinations, or delusions outside of plant medicine use?

No

Yes

Do you have a personal or family history of schizophrenia, bipolar disorder, or severe mental illness?

No

Yes

3. MEDICATIONS & SUBSTANCES:

Are you currently taking any medications?

No

Yes

If yes, please list:

Specifically, are you taking any of the following?

Do you regularly consume alcohol?

No

Yes

If yes, how often/how much?

Do you currently or have you recently used recreational drugs? (e.g., cannabis, cocaine, MDMA, ketamine, etc.)

No

Yes

If yes, please list substances & frequency:

4. CEREMONY READINESS:

Have you participated in plant medicine or psychedelic ceremonies before?

No

Yes

If yes, which ones and when?

What is your intention for joining this ceremony? Is there anything else you feel it’s important for the facilitator to know about your health, lifestyle, or personal journey?

4. AGREEMENT

I affirm that the above information is true and complete to the best of my knowledge. I understand that withholding information about my health, medications, or substance use may put me at risk during the ceremony.

WAIVER & ACKNOWLEDGMENT

By submitting this form, I acknowledge that participation in the mushroom ceremony is entirely voluntary and involves personal choice. I understand that psilocybin experiences can have physical, emotional, and psychological effects, and I accept full responsibility for my own well-being.

I hereby release and hold harmless the organizers, facilitators, and hosts of this event from any and all liability, claims, or legal responsibility related to my participation. I confirm that I am choosing to participate at my own risk.

SIGNATURE (FIRST AND LAST NAME)

Join our mailing list