Name

First Name

Last Name

Where are you located? (City, State, or Country if outside the U.S.)

What’s drawing you to microdosing right now?

Have you worked with psilocybin before?

What would you hope to receive, explore, or shift during out time together?

Is there anything you'd like me to know about your current emotional, physical, or spiritual state?

Are you interested in a sliding scale or payment plan option?

Yes, sliding scale

Yes, payment plan

No, I'm planning to pay in full

I'm not sure yet

How did you hear about Pine & Prism?

After you submit your form, I'llbe in touch to schedule a free connection call. We’ll talk more about the container, answer any questions you have, and feel into whether it’s the right time and fit.

1:1 Microdosing Coaching Interest Form

Thank you for your interest in working together. This 1:1 container is an intimate space, and I want to make sure it feels like a good fit with where you are and what you're seeking. Please take a few minutes to share more about your path — there's no pressure, just an invitation to begin with intention.