An assessment questionnaire

Fill out the assessment questionnaire and our specialists will contact you to assist

STEP 1: General information

First Name (Required)

Last Name (Required)

Email (Required)

Height (Required)

Age (Required)

Phone (Required)

Sex (Required)

Weight, POUNDS (Required)

Status (Required)

STEP 2: Mental Ailments

Primary Concern (Required)

Emotional Vulnerability (Required)

Mental Stability (Required)

Mood Swings (Required)

Are you currently on any medication?(Required)

Medication (if yes, list them)

Social Triggers

If Yes, please list them.

Past Trauma

If Yes, please describe briefly.

Diet (Required)

Hydration (Required)

Alcohol Use (Required)

Smoking (Required)

Sleep (Required)

Exercise (Required)

Choose a number from 1 to 100 (Required)

Please enter a number from 1 to 100.

Preferred contact method(Required)

STEP 3: CHOOSE YOUR DOSAGE

Mushly. Edible, Medical, Psilocybin & Mushroom Info

Micro Dose

Low Dose

Normal Dose

High Dose

Your privacy is paramount to us. Rest assured that the personal and health information you provide will be kept strictly confidential and will not be sold or shared with any third parties. It will be utilized solely for the purpose of providing you with the assistance and services you seek from us. We employ robust security measures to safeguard your data. For more detailed information, please view our Privacy Policy.