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Psychedelic Passage Client Application

If you are interested in working with Psychedelic Passage, please fill out an application. Each application is individually reviewed to to ensure that we are a good fit for one another.

Please note:

  • If you have already worked with Psychedelic Passage, you’ll still need to complete another application so we have the most current information on file
  • Psychedelic Passage reserves the right to refuse service to applicants based on your responses
  • If you are interested in a couples or group program, each participant must submit their own application

Statement of Confidentiality and Privacy

Psychedelic Passage and client acknowledge that all of the information on this document shall be regarded confidential and private. It is therefore agreed that any information received by one party from the other shall not be disclosed by either party to any third party and shall not be used by either party for purposes other than for the screening of the client for potential participation in Psychedelic Passage’s services.

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