Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Have you accessed any NHS services for a mental health issue? *

GP

NHS brief talking therapy or counselling

Specialist mental health service

Community Mental Health Team or Recovery Team

Admission to a mental health inpatient ward

None of the above

When was your most recent contact with one of these NHS services (if applicable)

MM

DD

YYYY

Do you use any of the following recreational drugs? *

Tick all that apply

No I never use any recreational drugs

Cannabis

Cocaine

Ketamine

Ecstasy

Opioids

Psilocybin (Magic Mushrooms/Shrooms)

MDMA

LSD

Ayahuasca or other plant-based psychodelics

Other

Your address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of kin *

Emergency contact

First Name

Last Name

Next of kin phone number *

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