Application - Cannabis Assisted Therapy

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Cannabis Assisted Therapy Application

Contact Information

First Name

Last Name

Phone

Background Information

Why would you like to do CAT?

What benefits would you like to see?

Which difficulties do you think you might encounter and how might you try to overcome them?

Do you have any specific fears about CAT?

Have you had any particularly traumatic experiences that may come up for you?

Have you ever been suspected or diagnosed of having psychiatric disorders or conditions?

Are you currently taking any Vitamins or other medications?

Have you taken other drugs what experiences have you had?

Emergency Contact

First Name

Last Name

Phone

Other

How have you been feeling in the last few days?

Are you ok with us using touching, in the way of support, your hands, feet, or shoulders if you need comforting? This can be one or both of us and you can change your decision at any time. No judgment as your safety is our highest priority. This may change as you feel into each moment and we respect your feelings and decision.

Do you have a history of, or currently suffer from any of the following? (Please tick)

Cardiovascular disease, including heart attacks

High blood pressure

Severe mental illness

Recent surgery

Past or recent physical injuries, including fractures or dislocations

Recent or current infectious or communicable diseases

Glaucoma

Retinal detachment

Epilepsy

Osteoporosis

Asthma (if “Yes,” please bring your inhaler)

Please expand on any of the above ticked boxes

Are you currently pregnant? *

Yes

I declare that the above information is correct and current. I agree to the terms & conditions.

Exclusion will include significant psychiatric disorders such as schizophrenia or bi-polar disorder, pregnancy, heart disease, glaucoma, epilepsy and other significant medical treatments. Conditions such as heart disease, cerebral vascular disease, psychotic illness, and use of certain medications will be an absolute contraindication to use of, or access to, Psychedelic Assisted Therapy.

Thanks for submitting!

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