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This form is to be completed by your Therapist. Please send this link to your therapist and it will be submitted directly to Rejuva to be attached to your application. Ideally, this is someone you have an ongoing relationship with and understands your desire to apply for psilocybin therapy.

    First Name*
    Client's Name for whom your are completing this form:

    Last Name*
    Client's Name for whom your are completing this form:

    Client Date of Birth *

    First Name *
    Therapist (your) Name:

    Last Name *
    Therapist (your) Name:

    Credentials, Licence #, Designation *

    Email *

    Phone *

    Website for Therapy Practice, if applicable

    Preferred method of Contact *


    Consent to call if unable to reach through other methods *


    How many sessions have you had with this client? *

    Additional comments regarding number of sessions with client if necessary


    Briefly describe the challenges this client has been facing. *
    To the best of your knowledge, please describe previous therapy treatments (pharmaceutical, talk, etc) this client has tried and how they may have helped or not helped. Please note that these comments will be included in the application for the client to The Honourable Patty Hajdu.


    Please express any support and/or concerns you may have with psilocybin treatment for this client. *
    Please note that these comments will be included in the application for the client to The Honourable Patty Hajdu.


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