Thank you for your interest in our 12-week Rewire Programme Microdosing for Women who want to Change the World!

Please complete this form fully and honestly. All personal information is strictly confidential and will be treated securely.

Thank you,
Naz & Rachel

Co-Founders, Women are the Medicine

____________________________________________________

About You

First Name *

Last Name *

Date of birth *

Email *

Phone *

What is your current occupation? *

Country of residence *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
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Serbia
Seychelles
Sierra Leone
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Slovenia
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Somalia
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Thailand
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Ukraine
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Uruguay
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Virgin Islands, U.S.
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What is your timezone? *

What are the three biggest changes you want to make in your life? (This could be in your business/career, your relationships, health/wellbeing, finances, spiritual development, your environment...)

What are the biggest obstacles holding you back? *

What would you like to contribute to the world? *

On a scale of 1 - Jane Fonda how awesome are you? *

Programme dates and times

Please review the times below tick all that you are available for. If you have a strong preference let us know in the comments section. In the case there ar enough applicants we will run 2 cohorts but otherwise we will go with the majority.

Please note, each session will be 60 mins (plus an additional optional 30mins for coaching/discussion/feedback).

Please select the times you can do *

Wednesdays at 10am UK

Wednesdays at 3pm UK

I can do both/either

Comments

You and Microdosing

Are you new to microdosing? *

YES

If you answered No (i.e. you have microdosed before) please tell us a little about how you found the experience (positives, negatives?)

Medical Declaration

How would you rate your current physical health? *

Excellent

Good

Satisfactory

Unsatisfactory

Poor

Do you experience issues with any of the following? *

Sleep

Appetite (under or over eating)

Chronic Pain

Headaches or Migraines

None of the above

How would you rate your overall mental health? *

Excellent

Good

Satisfactory

Unsatisfactory

Poor

Are you currently experiencing any of the following? Please tick any that apply *

Overwhelming sadness or grief

Anxiety

OCD

Panic Attacks

Phobias

None of the above

Are you currently taking (or in the last 6 months taken) any form of prescription medication? *

YES
NO
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If you answered yes to the last question, please detail what type(s) of medication with the BRAND name and how long you have been taking each

Have you previously accessed mental health therapies/services (e.g. psychotherapy, psychiatric services)? *

YES
NO
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If you answered yes to the last question, please detail what type(s) of mental health therapies/services you received and approximate dates (if more than once, please give dates for each) Please also confirm if you have ever been prescribed psychiatric medication - YES/NO, and if YES give details

Potential Contraindications

It's important to recognise that, as with any compounds taken medicinally, there are both physiological and psychological conditions which need to be screened out when it comes to psychoactive substance use.

Not all of these contraindications rule out the use of psychedelics - they do however need to be considered very carefully, as they can cause serious long-term damage if not acknowledged before going into a psychedelic experience.

Please select any/all of the following that apply to you: *

Personal history of schizophrenia

Personal history of bipolar disorder

Personal history of severe depression

Family medical history of schizophrenia or bipolar disorder

Active suicidal ideation or previous attempts

Major emotional dysregulation

Currently taking SSRI or MAOI medication

Very high blood pressure

Very low blood pressure

Heart arrhythmia or irregular heart beat

Cardiac or coronary issues

Personal or family history of epilepsy/seizures

None of the above

Do you have a personal history of physical, developmental/childhood, or mental trauma? If yes, please be aware we will need to discuss this in more detail to assess your suitability for using psychedelics. *

Finally, is there anything else you'd like us to know about you in terms of your physical, mental, emotional, relational, professional and spiritual health?

I hereby confirm that, to the best of my knowledge, the provided information is true and accurate.

I agree that by providing my email and phone number, I consent to receive email and text messages from Women are the Medicine. in relation to my application.