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Online Participation Intake, Consent & Waiver Form


Review Higher Growth Integration Privacy Policy

Psychedelic Preparation & Harm Reduction Program Consent & Waiver

Welcome to our online Psychedelic Preparation & Harm Reduction Program.  Please review the following information and when you are ready sign the informed consent and waiver at the end of the document.

Program Purpose

This program is a unique kind of experience where a group of people with a shared interest in the potential of psychedelics for personal growth and healing gather to learn and share their intentions and experiences with each other. It is our priority to create and maintain a safe environment that is conducive for sharing and where people can grow and trust one another.

Please note: Psychedelic integration is not about encouraging the consumption of psychedelics, it is about harm reduction and pre/post consumption management. We do not provide any substances, nor do we provide directions on how to obtain controlled substances.

Confidentiality

Every effort will be made to keep your personal information private. However, there are some limitations to confidentiality. We will release information when a student poses a risk to themselves or others and in cases of abuse to children and/or vulnerable adults. If we receive a court order or subpoena, we may also be required to release some information.

Some students may choose to use technology (e.g. telephone, email, text) in communicating with Higher Growth. Every precaution to safeguard your information will be taken but we cannot guarantee that unauthorized access to electronic communications will not occur. On your side, please take precautions with authorized and unauthorized access to your technology.

Please note that if you have been in, or are currently in, a counselling relationship with one of our group facilitators, your confidentiality will also be maintained. If you decide to share this in the group that is your choice, but we will not speak to it nor share any details of your private therapy. Also, if you happen to see one of your facilitators outside of group, in public, they will protect your privacy by not greeting or addressing you unless you greet them first.

Potential Benefits & Risks

This program requires your active effort to learn and connect. To be most successful you will need to also do work outside of group sessions. It is important to note that your group facilitators are not medical doctors. Information shared in this program is educational and is not medical advice. There can be discomfort involved in participating in the processes of this group. You may remember unpleasant events, or experience feelings of anger, fear, anxiety, sadness, frustration, loneliness, helplessness, or other unpleasant feelings. If these, or any other stressful emotions arise during a group session, please talk with one of your group facilitators.

Contact

Please contact us through the email address info@highergrowth.ca Your correspondence will be returned as soon as possible, but it may take several business days. If you cannot wait for a return call or it is an emergency situation, please go to your local hospital. If you are on Vancouver Island, please contact the 24 hour VI Crisis Line at 1-888-494-3888 (http://www.vicrisis.ca).

Group Guidelines

For the safety of the group it is necessary that all members comply with the following guidelines:

-Stories and group discussions will not be shared or discussed outside of the group unless express permission has been given by the owner of the story.

-Members will be respectful of each other.

-Members will not attend the group session under the influence of, or in the possession of any controlled substances.

By signing this form, I confirm that I understand the purpose, expectations, possible benefits, risks, emergency procedures, confidentiality policies, and group guidelines of this program and I consent to participate in the group process.

I Agree
 

WAIVER

Although some research has demonstrated that psychedelics can be helpful in personal growth and psychotherapy, at no point has Higher Growth (nor will they) ever prescribed or stated that taking a psychedelic will be helpful in the treatment of anyone’s mental health or personal issues. This group program is intended to be educational and is not a substitute for professional medical care, individual therapeutic treatment, or legal advice. Any application of the information and materials shared in this program is at the student’s discretion and is their sole responsibility. Higher Growth does not, nor do any of the program facilitators, assume any responsibility for physical, psychological, legal or social consequences resulting from the application of information obtained through this program.

I undertake responsibility for any and all risks that I incur from attending this group program.

I Agree
  

Intake Questions - Please answer the following questions so we can get to know you a bit better:
1. Why are you participating in this program?

Click to enter your response. *
2. Please tell us a bit about your level of experience (if any) with psychedelics &/or cannabis.

Click to enter your response. *
3. What is your comfort level with sharing & hearing others share about vulnerable & potentially difficult or uncomfortable experiences or feelings?

Click to enter your response. *
First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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