PSILOCYBIN MUSHROOM CEREMONY

PARTICIPATION AGREEMENT AND RELEASE OF LIABILITY

First name

Last name

Date of birth

Year

Month

Day

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

Yes

If yes, please describe:

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

Yes

If yes, please describe:

Have you ever been diagnosed with a mental health condition?

Yes

If yes, please describe:

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

Yes

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

Yes

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

Yes

Are you currently taking any medications?"

Yes

If yes, please describe:

Do you regularly consume alcohol?

Yes

If yes, how often/how much?

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

Yes

If yes, please list substances & frequency:

Have you participated in plant medicine or psychedelic ceremonies before?

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?

1. Acknowledgment of Nature of Ceremony

I acknowledge that I am voluntarily participating in a psilocybin mushroom ceremony. I understand that psilocybin is a psychoactive substance that may produce altered states of consciousness, changes in perception, emotional intensity, and psychological effects that may be unpredictable.

I understand that this ceremony is not medical treatment, psychotherapy, or a substitute for professional medical or mental health care.

2. Voluntary Participation

I confirm that my participation is entirely voluntary. I have chosen to attend of my own free will and may decline participation at any time.

3. Assumption of Risk

I understand that participation in a psilocybin ceremony involves inherent risks, including but not limited to:

Emotional distress
Anxiety or panic
Physical discomfort
Nausea or vomiting
Psychological distress
Re-emergence of past trauma
Disorientation or impaired coordination

I understand that effects may continue after the ceremony and may require integration support.

I voluntarily assume full responsibility for any risks, injuries, or damages, known or unknown, which may arise from my participation.

4. Health Disclosure and Personal Responsibility

I affirm that:

I am not currently under the influence of alcohol or recreational drugs.
I do not have a diagnosed psychotic disorder, schizophrenia, bipolar disorder, or other serious psychiatric condition.
I am not currently taking medications that may negatively interact with psilocybin (including but not limited to SSRIs, MAOIs, or other psychiatric medications).
I am not pregnant or breastfeeding.
I have disclosed any relevant medical or psychological conditions to the facilitator.

I understand it is my responsibility to consult a qualified medical professional prior to participating if I have any concerns.

I declare that the info I’ve provided is accurate and complete.

By signing below or clicking the confirmation box on the website, I acknowledge that I have read and fully understand this waiver. I agree to participate in the retreat at my own risk and release the organizers and event venue from all liability to the fullest extent permitted by law.

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)

PSILOCYBIN MUSHROOM CEREMONY

1. Acknowledgment of Nature of Ceremony

2. Voluntary Participation

3. Assumption of Risk

4. Health Disclosure and Personal Responsibility

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