For Clinicians

We are happy to meet your patients and help them heal through out psychedelic-assisted therapy program. Please submit their information in the referral form below and we will reach out to them.

Patient Information

Name *

First

Last

Date of birth *

Gender *

Email *

Phone *

Referring Practitioner Information

Name *

First

Last

Email *

Phone *

FAX *

Practice Name *

Practice Address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Reason for Referral

Please share pertinent clinical information: diagnosis, treatment history & indication.