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This form is to be completed by your physician. Ideally, this physician is your regular or family physician. Please send or bring this to your physician and it will be submitted directly to Rejuva to be attached to your application.

    Patient First Name*

    Patient Last Name*

    Patient Date of Birth *

    Physician Name *

    Physician Email *

    Physician Phone *

    Medical / Psychiatric Criteria for Consideration of Psilocybin-Assisted Therapy

    This form has been created by the Alberta Medical Team with Syntac Institute including a Psychiatrist and a Palliative Care physician. Syntac Institute has provided this treatment for previous Section 56 Exemption applications that have been approved by Health Canada. This form is for the exclusive use in the named patient's application for the Section 56 Exemption application to the office of The Honourable Patty Hadju. Please review the following and provide additional information as required.

    If you would like to find more information about the safety and efficacy of psilocybin treatment, one such article linked here describes one of the rigorous scientific studies that has been done.

    Administration of psilocybin can be physically and emotionally stimulating, potentially inducing physiologic changes similar to mild/moderate physical exertion that may continue for 6-8 hours. Patients should not have active uncontrolled medical conditions that may significantly impair physical or cognitive function.

    MEDICAL CONSIDERATIONS: Cardiovascular *



    The presence of any of the following may require further medication consultation:
    Clinically significant ECG abnormality
    Significant peripheral vascular disease (e.g. claudication)

    Optional comments


    MEDICAL CONSIDERATIONS: Neurologic *



    The presence of any of the following may require further medication consultation:

    TIA in past 6 months
    History of stroke
    History of traumatic brain injury
    Other medical conditions affecting brain function (e.g. encephalopathy)
    Other progressive or degenerative neurological conditions



    MEDICAL CONSIDERATIONS: Other *



    If controlled with insulin or oral hypoglycemic agents, then no recent history of hypoglycemia or instability.
    Suggestion for physical/neurological exam, CBC, electrolytes, EKG, TSH unless this has been done recently (in the past year) and patient is medically stable.

    Optional comments


    If Patient is Female *


    Pharmacologic Considerations:

    If the patient is taking the prescription medication regularly, it is recommended that they have been on stable doses of those medications for sufficient time to establish a stable state (generally at least 5 half-lives, and more in certain cases).

    Please make note of any recent or anticipated changes in prescribed medications.

    SSRIs, TCAs and SNRIs may be tapered if the treatment team considers it safe to do so. (These medications may interfere with the therapeutic effect of psilocybin. There is also a theoretical risk of serotonin syndrome in combination with psilocybin, although literature support for this is scant at this time.)

    Depending on the urgency of the situation, it is best to have at least one drug free week before use of psilocybin.

    Tapering may generally be safely accomplished by reducing dosages at intervals of 5 half-lives, with regular monitoring of patient.

    Pharmacological considerations *

    Optional comments


    Psychiatric Considerations:

    Does not suffer from any psychiatric condition judged to be incompatible with establishment of rapport or safe exposure to psilocybin. Psychiatric consultation is recommended in all doubtful cases.

    PSYCHIATRIC CONSIDERATIONS *

    Optional comments


    Please attach any supplemental explanatory notes as needed and do not hesitate to request a phone consult with Dr. Stephen Peach to determine psychiatric eligibility.


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