Full name *

Email *

What is your phone number so I can reach you? *

Address

Street Address

City

State

Country

Postal code

What is your age? *

30-40

40-50

50+

What service did you sign up for?

Psilocybin Microdosing Protocol

Psilocybin Ceremony

Coaching Package

Energy Alignment Session

Please describe what you are seeking my services for. What led to it and what would be your desired outcome? *

Do you have a history of sexual or physical abuse? *

Do you have a history of addiction? *

Do you take any medication? *

Do you have a history of emotional or mental abuse/neglect? This includes narcissistic abuse. *

Do you have a history of repeated patterns that do not serve you (e.g., "I keep experiencing the same thing over and over")? *

Do you have documented Traumatic Brain Injury? *

If you answered yes to either of the 6-9 questions, please elaborate with more detail including ages when things have happened. *

Have you had any form of therapy/coaching before? If no - please elaborate why not. If yes - please describe the type of therapy/coaching, what for, how long, and its effectiveness. *

I understand that Divine Light Collective services are not medical or psychological treatment.

Yes

I voluntarily assume responsibility for my participation and release Divine Light Collective from liability to the fullest extent permitted by law.

Yes

I understand deposits are non-refundable and late cancellations/no-shows may forfeit payment.

Yes

I confirm that the information I provided is accurate to the best of my knowledge.

Yes

consent to photo/video usage for promotional purposes.

Yes

No

I have read and agree to the Terms & Conditions and Waiver.

Yes

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