Get Started

with Holistic TherapeutiX

Completion of this form is required before starting any sessions with Holistic TherapeutiX and to access the Client Portal area of the website. If you run into any questions, please contact us directly

Registration

As we prepare to tailor our sessions to your needs, we require some essential information from you. Please be assured that your privacy is of utmost importance to us. All information shared will be handled with strict confidentiality and will not be disclosed to anyone outside of the Holistic TherapeutiX team. The services offered at Holistic TherapeutiX are designed to complement, not replace, any ongoing therapy or medical treatment you may be receiving.

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Personal Information

Name*
MM slash DD slash YYYY
Address*
Preferred contact method*
How did you hear about Holistic Therapeutix?*

Safety Self-Assessment Questions

Will this be your first time using cannabis?
If not, have you used cannabis regularly or casually?
Have you ever had extremely unusual or disconcerting thoughts or ideas or extreme levels of energy (inability to sleep for days or racing thoughts, or alternatively extremely low energy) after the effects of a psychedelic/cannabis should have worn off?
Do you have any past or present medical conditions (physical or mental health) that may affect your ability to participate safely in our session/event?
Have you ever required significant treatment or been hospitalized for a psychological or emotional disorder or other psychological or emotional reason?
Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically, emotionally, or otherwise?
Has a health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or use altered state practices?
Have you ever experienced extreme paranoia or anxiety, panic attacks, or other extreme negative experiences while using cannabis, any psychedelic drugs, or any other times that required a significant intervention?
Have you ever fainted or blacked out, or otherwise adversely lost consciousness while on cannabis or any psychedelic medicine?
Are you pregnant or nursing?
Do you have acute, current, or past substance abuse/dependence issues?
Are you currently on any medications, supplements, or recreational drugs that could affect your safely participating?
Do you have a history of disruptive or violent behavior, either physical or emotional?
Do you have a history of traumatic or difficult life events that have not been addressed or are not being supported therapeutically?
Do you have any present concerns about suicide or self-harm?
Are you extremely anxious as you contemplate attending our services?
Have you recently had a major transformational experience with a psychedelic medicine or otherwise that feels almost complete but not quite or unresolved?
Do you ever feel extremely uncomfortable in group transformational processes?
Which session are you interested in participating in first?*
A list of the available sessions and their descriptions can be found here.
Newsletter
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