ANSWER YES / NO TO THE FOLLOWING...

1. Are you pregnant or nursing?

2. Do you have any past or present medical conditions (either physical or mental health) that may affect your ability to safely participate in this program?

A psychedelic experience is not appropriate for persons with cardiovascular problems, severe

hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy?

3. Have you ever been diagnosed with, or required significant treatment for, a psychological or emotional disorder, or for any other psychological or emotional reason?

4. Have you ever been hospitalized for a psychological or emotional disorder, or for any other psychological or emotional reason?

5. Have you ever had a severe, adverse reaction to using cannabis or other psychedelic medicines, physically, emotionally or otherwise?

6. Has a health professional ever advised you to cease or otherwise limit consumption of cannabis, psychedelic medicines, or using altered states practices?

7. Have you ever experienced extreme paranoia, anxiety, panic attacks, or other extreme negative experiences while using cannabis, any psychedelic medicines, or during any other time in your life that required a significant intervention?

8. Have you ever dealt with a pattern of unstable

relationships that caused you significant distress?

9. Have you ever fainted or blacked out or otherwise adversely lost consciousness while on cannabis or any psychedelic medicine?

10. Have you ever had extremely unusual or disconcerting thoughts or ideas, or extreme levels of energy (inability to sleep well for days, racing thoughts, or alternatively extremely low energy) after the effects of a psychedelic or cannabis should have worn off?

11. Have you ever seen or heard things or people that weren’t there after the effects of a psychedelic or cannabis should have worn off?

12. Have you ever obsessed over an idea or belief in a way that has caused difficulties in your life?

13. Do you have any acute, current or past substance abuse/dependence issues?

14. Are you currently on any medications, supplements

or recreational drugs that could affect you safely participating in a psychedelic experience?

(if you are unsure, please contact me at

breathe.dtla@gmail.com to discuss)

15. Do you have a history of disruptive or violent behavior, either physical or emotional?

16. Do you have a history of traumatic or difficult life events that has not been addressed or is not being supported therapeutically?

17. Do you have any past or present concerns around suicide or self-harm?

18. As you contemplate attending this experience, or when checking in with yourself right before it begins, are you extremely anxious?

19. Have you recently had a major transformational experience, with a psychedelic medicine or otherwise, that feels almost complete but not quite, or unresolved?

20. Do you ever feel extremely uncomfortable in group transformational processes?

21. Are you currently employed, a student, or otherwise financially stable?

22. Do you have a safe home environment and a stable residence?

23. Have you ever been or are you currently involved in any legal proceedings? Criminal or civil?

This Safety Assessment is taken from my training with Medicinal Mindfulness.