Name
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First Name
Last Name
Email
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Birth Date
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MM
DD
YYYY
Please share your intentions for this program:
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Are you currently taking any prescription medicines?
If yes, please list all medications, dosages, duration of use, and reasons for taking them.
Do you have any medication allergies?
If yes, please list all allergies and reactions.
Do you have any food allergies or restrictions?
If yes, please list all allergies and reactions.
Are you currently taking any supplement medications, including natural herbs?
If yes, please list all supplements and herbs.
Select symptoms that you are currently or have recently experienced:
If yes, please provide details, including dates and treatments.
Select conditions that apply to you:
If yes, please provide details below.
Do you have or have you ever had heart issues?
If yes, please provide details, including dates and treatments.
Have you been hospitalized in the last 10 years?
If yes, please provide details, including dates and treatments.
Have you or any family member been diagnosed with or suspected of having psychiatric conditions?
Do you have or have you been diagnosed with depression?
Do you have or have you been diagnosed with anxiety?
If you answered yes to any of the above, please provide details, including dates and treatments.
Please state any physical or mental limitations and restrictions. If none, type 'N/A' and your initials.
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Do you have a relationship with a substance or behavior that you would like to change?
If yes, please describe.
Who or what supports you? Where do you turn for support?
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Do you have a mindfulness practice (journaling/meditation, etc.)? If so, please describe:
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How many hours of sleep do you get at night, on average?
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Have you seen in the past, or are you currently seeing, a therapist or a mental health professional?
If yes, when was the last time you saw them and/or how often do you see them?
Please describe your experience with any recreational drugs or psychedelics, including dosage and when consumed.
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When was the last time you used a recreational drug or psychedelic? (includes ayahuasca, cannabis, cocaine, DMT, Iboga/ibogaine, Ketamine, LSD, MDMA, psilocybin mushrooms, etc.)
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Have you ever had a challenging experience with a psychedelic or recreational drug? If so, please describe.
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Do you have any immediate concerns or pressing matters? If so, please describe.
By participating, I understand that NeuroPilot's services are not a substitute for medical treatment, therapy, or psychological counseling. I am responsible for my own well-being during the course of any services received.
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NeuroPilot and its facilitators are not practicing medicine, diagnosing, curing, or treating diseases or illnesses. I understand they are not my therapist, counselor, or psychotherapist.
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I acknowledge these services are for my personal benefit and development. I will keep all aspects of these services confidential, including resources, pricing, facilitators' information, and service locations.
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I assume all risks associated with participating in these services and release NeuroPilot, Matt Sroda, facilitators, and organizers from all liabilities arising from my participation.
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I certify I am in good physical and mental condition, aware of the risks involved, and voluntarily assume full responsibility for any loss, damage, or injury sustained.
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By clicking 'Yes', I attest that all information provided is true and correct. I agree to notify NeuroPilot and the facilitators immediately if any representations change during my participation in the program.
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By typing my name and date below, I certify and agree to all statements agreed to and data obtained in this form:
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