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Program Intake Form

Please complete this short form so we can safely guide you through the upcoming program.

First name

Last name

Which program are you registering for?

Do you have previous experience with plant medicines? *

No

Yes

Are you taking any medications currently? *

No

Yes

Have you been diagnosed with any mental health conditions? *

No

Yes

Tell us about your intention for the program.

Please sign below to confirm that the information provided is complete and accurate. .

Today's Date

Thank you! We'll contact you if any questions on your form.

let's connect!

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katie@lovecollectiveco.com

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