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This form is to be filled out by you. This gives a more in-depth understanding of the challenges you are facing and includes an opportunity to make your appeal to The Honourable Patty Hajdu for consideration of the approval of your application.

    Last Name*

    Date of Birth*

    City* Province*

    Postal Code*

    Email Address*
    Phone Number*

    Preferred method of contact*

    Do you give us consent to call you if we are unable to reach you through other methods? *

    Name of Therapist*

    Are you taking prescription or non-prescription medications?*

    Please detail and describe the purpose, dose, frequency and duration of each medication you are taking.*

    Do you have and current or resolved mental health condition? Choose any/all that apply. *

    Other mental health conditions. Please detail below

    Please provide further details regarding current or resolved mental health conditions you referred to above. *

    In the box below, please share your compelling story of why you feel psilocybin therapy would be beneficial to your healing process. *

    This information will be shared directly in a letter on your behalf with The Honourable Patty Hajdu. Please include why you want to try psilocybin therapy, conditions you have dealt with in the past and are currently dealing with, treatment history, medications and therapies you have tried, what is working/not working, impact on your life (socially, personally, economically, family relationships, etc) and what outcomes you would like to see with this psilocybin therapy. As psychedelics are not legal for consumption outside of the Section 56 Exemption in Canada, please do not reference any use of these in your appeal below. Please begin your story and details with "Dear Honourable Patty Hajdu,"

    I confirm that I have read and accepted Rejuva's Privacy and Terms.*