First Name *

Last Name *

Phone *

Email *

Preferred method of communication *

Phone

Email

Text Message

Weight *

BMI *

Please check any and all of the following medical conditions that you CURRENTLY have *

Are you taking any supplements? *

Yes

No

Have you had any surgeries we should be aware of? *

Yes

No

Have you been diagnosed with any mental health conditions? *

Yes

No

Did you experience any significant stress or trauma during childhood? *

Yes

No

Have you ever been diagnosed with or experienced symptoms of an eating disorder? *

Yes

No

Have you ever been hospitalized for a mental health or psychiatric reason? *

Yes

No

Have you ever attempted suicide? *

Yes

No

Do any of your biological family members have a history of mental health or psychiatric diagnoses? *

Yes

No

What is your gender? *

What is your sexual orientation? *

Do you have children? *

Yes

No

What is your current occupation? *

What is the highest level of education you have completed? *

Have you ever used Kratom? *

Yes

No

Have you ever used a substance intravenously (by injection)? *

Yes

No

Do you currently have a valid passport that will remain valid for travel to Mexico in January 2027? *

Yes

No

Please note that every field in this application must be completed. Enter ‘N/A’ if a question does not apply.

PMH/PSH

Please note you will be required to submit results of an EKG to your doctor to be approved.

Prescription Medication #1

Prescription Medication #2

Prescription Medication #3

Supplement #1

Supplement #2

Supplement #3

Surgery #1

Surgery #2

Surgery #3

Mental Health History

Social & Personal History

Substance Use, Coping & Treatment History