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Contact Information
Background Information
Emergency Contact
Do you have a history of, or currently suffer from any of the following? (Please tick)
Are you currently pregnant?

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.

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