Mycosomatic Mase PERSONAL INFORMATION FORM. experiences wth Pslocybe Mushroom Pease read the question and answer in detall nd honesty Your answers are completly condentil and are Intended te custom-design te experince First and last name: Erk Selon gests Height 282em Weight7 ke Telephone: +4791709017 —_whatsApe?y__(VN) 1. Have you had previous experiences with mushrooms, psychedels, cannabis, or other psychoactive substances? yes, ‘how many times, what wore the substances & dosages nd how dd you feel about those experiences? 23-4 times, Ayahuasea in small group Ina traditional setting (3 small cups), magic mushroom with guide (5 died), tried marivana (smoke). Have you had any avers effets rom taking these substances? No Have you had any experionces thet were portly dificlt nthe moment or difiuit ointgrate afterwards? No, 2. Have you suffered, do you suffer, o do you havea family history ofthese pathologies? + Cariovaculardzeses, including heat attacks: No = ypertension: No Diagnosed psyehiatr ess: No Recent surgery: No Physical injuries, facture, dslocations, resent or past accidents: No Contagious diseases Ho - Glaucoma No “Retinal detachment: No + Epllepsy No Osteoporosis No - Asta! No, but weed asta spray shorter period when runing intervals 3. Are you current pregnant or planning to become pregnant? No4 Have you been hospitalized at any tne nthe ast 20 years for medial reasons? ave been to hospital believe twas in 2014) ate fallen down a sti. Competly and documented) recovery 5 Have you ever been hospitalized fr psychiatric reasons? No, 6. Do you havea family history of psychiatric isorders? No, 2. Are you current in therapy ona support group? l use a coach today for suport after duorce 18 months ago and {or planning my professional career going further 8. Are you taking any typeof medication? No 9. Have you ever ha sud thoughts? No 10. what your motivation fr patspating ln this experience? Healing an reset; support my personal development Using mindfulness meditation in onder to be Kader to set and more posite and appreciative in fe. "Good enough Ease the struggle 11. genera whats the qualty of your sleep? (Ona scale of to 10,1 bing tril, 10 beng perfect) 6 12, What isyour tolerance to aleohor? (ona scale of 10 10,1 being extremely sensitive, 10 being extremely high tolerance) a 13 lsthere anything ese about your emotional or physical tate that we should know? No. Si some struggle emotional afte divorce 18 months ago. 14, How di you fi aut about ws, and why dd you choose us? Google, Wanted to check posible inthe time travelto Ronda, Person to contac incase of emergencyName (and relationship: Gry eteend) Phones47 40872075 IF youhave answered yest any ofthe above question, ts important that you etal your answer a uly a possible. does not necessary equality you from participating nthe experience. We willcontat youtoconfirm your participation ora addtional questions to ensure your safety. INFORMED CONSENT STATEMENT Please read ad sig the following informed consent statement. Please mae sure you read ané understand every section, Ifyou donot understand any part of this document, please ask you alitator fr clifton before siging 4 understand that pllocybe mushrooms do not requte medial dlagnosis or reeraland tat psloybe mush- ‘oom are nota medal o clinical treatment. 2. understand that plloeybe mushrooms have nat been approve bythe rganzacén Média Coleial de Espa or the European Medicines gency 2 Despite theirlock of pharmaceutics approval research suggests that ploebincontining mushroomsare ery “nll tobe adic, Atonally, research ond other information suggest that psoeybin may improve symp- toms of depression, anwety, endo fe stress, various forms of trauma, and probleratic substance use. 3 understand that under Spanish law psiocybe mushrooms, a natural products wth an established tration of Use inaltemative healing modaltes arent scheduled sbstances, and are therefore ful legal to consume 14 Tnderstand that under Spanish aw personal posession and consumption of al subs.ances, whether scheduled ‘or not, legal within private spaces. 5. understand that the rks, benefits, and drug Interactions of psllocybin are not fly understood, and Individual resus may vary 6. understand tnt ome people nave found pstocybe mushroom Sessions to be cnatenging or uncomfortable ‘common potential sie effects include nauees, mild headache, fatigue, ansety,confsion increase biood pes ‘sure, elevated heart rte, paranoia, perceptual changes, aered thought pattems, reduced inhibitions, reovery Cf repressed memories and pas traumas, and altered perception of time and one's suroundings. I they occur, these side effects are usual i and temporary. Because the potential sks and benefits of pllocybe mushroom ‘consumption are nt fly understood, there may be unanticipated side effects, 2. understand tat fam taking prescrition medications or have a medical condtion or mental heath condition, | shoul consider consulting with a medial or inca provider before patlpating nan administration session. 48, understand that pllocybin is derived from ful. If have a known mushroom alley, ! should const wit a ‘medial or cial provider before patipting in an administration session 19, understand thatthe rks of consuingpllacybe mushrooms wile pregnant or feeding with breast mil are unk, 10, understand that factatrs may not use touch whl providing ploybin services without my prior written com sent My faciitatr and | wl ccs acceptable types of supportive touch and the requirement to provide prior ‘writen consent prior tothe start of my administration session 1 (hereby affirm (ether affirm or withhold) my consent to receive supportive, non-sewal ‘ouch from my feltator appropriate) in order to provide comfort during my sesson. I hereby affirm (eltheraffiem or withheld) my consent to receive a fultbody massage to provide elavation during the start of my session 1, understand that consuming plloeybe mushzooms during the session f completely voluntary and | may decide rot to consume them at ny tine.Ae s s Mycosomatic. “Mawie 12, lunderstand that have the ight to update my persona information form prior te beginning an administration session ad have the right ta ecelve a copy of my information form upon request. 12, understand that if de-dentied anonymous} data collected by fcitators and serie centers is shared with people andinsitutions outside ofthe faclitater or research center, I must be provdeduth a dsclesure frm that ‘describes who wil receive the data and bow it wil be usd, and that have the opportunity to opt-out of having ‘ny anonymous data provided to tid paris. 1 Thereby aff affirm or withhold) my consent to share my anonymous data with lent ubictions and stutons forthe sake of furthering payehedele research 14 understand that my actator ay ake short restroom break ring my administration sesion. 45. understand that formyown safety, eaving these during an administration sssioncnce lt has begun strongly ‘scouraged. Doing so could lead to safety and legal ris 16, lunderstand and have been informed ofthe potential benef, sks, and complcationof psilocybin services with ‘my fcitatorto the extent that they are Keown, 1, Ihave had the opportunity to ask questons regarding anything | may nt understand or that beeve shouldbe made lar. 18, consuming whole fun! during an administration sesin, | understand that pslocyir content can vary between indvival ring bodes. 19, Tunderstand that the risks and benefits of repeated slob mushroom use are urkrown. 20. L understand that fect has city to callemergency services required anda patlpant assumes resp: lly for cost of emergency sevies 2, understand that | wil be required to enti an emergency contact and a fcitator may contact this person in ‘the event of medial or other emergency 2. understand that | may be charged a cancellation fee if cancel a scheduled preparaton administration o inte- ration sesion. | declare that | have read and understand the Information contained in this form. dedare that Ihave answered ll “questions honesty and in adequate detail and have nat omitted any information that conse important To the best ‘of my knowledge, my general physial and psychological health s adequate to proceed safely with the administration session. Name Erk Sonneland Date 21022024 Signature y Vi Sele prec ate], ‘Your personal dat ibe teated confidentially in accordance with the GDPR