Patient Information

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

Patient First Name *

Patient Last Name *

Patient Phone Number

Patient Email

Referring Practitioner Information

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

Practitioner First Name

Practitioner Last Name

Practitioner Email

Practitioner Phone

Practice Name

Reason For Referral

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

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