✨ Wild Glow Healing Center Pre-Screen Form

Thank you for your interest in Wild Glow Healing Center. Before moving forward, please complete this brief pre-screen. This helps us ensure medicine journeys are safe and appropriate for you.

🌿 Quick Safety Questions

1. Are you over the age of 21?

   • ☐ Yes

   • ☐ No

2. Are you currently pregnant, postpartum, or breastfeeding?

   • ☐ Yes

   • ☐ No

3. Do you currently take any of the following medications? (check all that apply)

   • ☐ GLP-1 medications (e.g., Wegovy, Ozempic, Mounjaro)

   • ☐ SSRIs (e.g., Lexapro, Prozac, Zoloft, Celexa)

   • ☐ SNRIs, MAOIs, or other serotonergic medications (e.g., Effexor, Cymbalta, trazodone, buspirone, triptans for migraines)

   • ☐ Other (please specify)

   • ☐ None

4. Do you have a history of psychosis, heart problems, blood pressure problems, schizophrenia, or untreated bipolar disorder?

   • ☐ Yes

   • ☐ No

5. Do you have a trusted therapist, and/ or an equivalent strong support system in place (family, community, spiritual guides)?

   • ☐ Yes

   • ☐ No

🌿 Readiness & Alignment

1. Have you previously experienced altered states (psychedelics, meditation, breathwork, ecstatic dance, etc.)?

   • ☐ Yes — with positive experiences

   • ☐ Yes — with mixed or difficult experiences

   • ☐ No

2. How do you feel about letting go of control and trusting the medicine process?

   • ☐ Open and willing

   • ☐ Unsure, but curious

   • ☐ Very uncomfortable

3. Do you understand that psychedelic medicine is not a one-time cure, but part of a larger healing process requiring preparation and integration?

   • ☐ Yes, I understand

   • ☐ No, I’m open to learning more about this

🌿 Logistics

1. Are you interested in a 1:1 journey, group journey, or not sure yet?

   • ☐ 1:1

   • ☐ Group

   • ☐ Not sure

2. Are you willing and able to maintain sobriety (from alcohol, cannabis, and other non-prescribed psychoactive substances) before and after your journey?

• ☐ Yes

• ☐ No