I agree to the following terms and conditions of becoming a member of this Medicine Membership.

Breathwork + Psychedelic Experience Agreement

Part 1. Psychedelic Experience

I, [client.name], agree to comply with the Psychedelic Experience Agreement in my psychedelic medicine use practices, as outlined below:

As representatives of the psychedelic community, we choose to exemplify safe psychedelic experiences. Safety allows for depth, healing and awakening, and is a universal right for all people in psychedelic spaces. The purpose of this agreement is to clarify expectations and appropriate behavior before we have a psychedelic experience together.

1. We affirm that this agreement can only be made in a sober state, and we agree that once any medicine is taken, even if the medicine hasn’t activated yet, we will not change the agreement until we are sober again, even if we all agree we want to. We agree to not break or change this agreement even if God/The Divine/The Universe/Truth, etc tells us directly and without a doubt to change it or break it.
2. We agree to respect each other’s boundaries, treat each other with respect, and keep each other safe.
3. We agree to complete a simple safety assessment BEFORE any journey, to be truthful about and discuss our current psychological state and life circumstances. We affirm that we are ready for the experience we’re choosing to have.
4. We agree to have a conversation around consensual touch before the medicine is taken. Touch is always consensual. Consent about something not discussed cannot be given after a medicine is imbibed. Permission is always requested and affirmed before touching. We agree that touch is never sexual in nature in a psychedelic therapy session.
5. We agree to be mindful of externalizing our inner experiences, and to be aware of our projections and transference (both positive and negative) that we may place on the experience, the facilitator or the medicine. We agree to discuss our perceptions, and to check in around feelings of safety, or sense of lack of safety, if we become anxious or paranoid.
6. We agree to keep confidentiality, and not share details of our experience with others, except in situations that require significant intervention to prevent harm, or where reporting is legally mandated, such as child or elder abuse, suicidality or self-harm.
7. We agree to have back up support in the form of a trusted emergency contact and to share the contact information with the facilitator or group. We agree to seek immediate professional support for any significant medical or mental health emergency.
8. We agree to only work with clean medicine that is tested, accurately measured, and responsibly sourced. We agree to be educated about the medicines we use and their legality.
9. We agree to only use medicines that we know are personally safe for us to use; physically, mentally, psychologically, and spiritually.
10. We agree to designate a specific location that represents the boundaries of the experience and to not leave the confines of this safe space until the completion of the experience. We agree to not bring into or do anything dangerous or harmful in the psychedelic experience space.
11. We agree that anyone imbibing a medicine will not drive following the journey until it is safe to do so.
12. We agree to communicate before the psychedelic experience about intention setting, safety assessments, and preparation support, and at least once after the experience for a safety check in and integration support.
13. As the sitter/guide of the experience, I agree to share my training and expertise verbally or through a disclosure statement and that I affirm to have adequate supervision support, training, and experience to facilitate the experience we are having safely. My fees are clearly outlined, will not change, and are in alignment with my skill, training, experience, and to similar services within my locale. I agree to only work within my scope of training and expertise, such as only doing body work if I am trained to do so, or only working with specific clinical concerns if I am trained to do so (such as trauma and PTSD and other significant mental health issues).

Much gratitude and best wishes for a safe and expansive journey!

The Psychedelic Experience Agreement by Medicinal Mindfulness is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Copyright © 2019 Medicinal Mindfulness Events LLC and Daniel McQueen.

https:// www.medicinalmindfulness.org/forms.

Part 2. Breathwork + Psychedelic Journey

I, the participant, (“Releasor/Participant”), understand that in participating in live breathwork journeys and/or entheogenic medicine journeys, pre-recorded video and/or audio journeys (collectively referred to as “Activities”) offered by We Are All Daughters, Samantha Williams, or Ellen Wong (“Releasees/Facilitator”), I agree to the following:

SERVICES & DISCLOSURE

I understand that breathwork and entheogenic-assisted journey Activities are designed to enhance quality of life and support holistic wellbeing, and are not intended to constitute medical advice or any substitution for medical care. I understand that Activities are not intended to be relied upon for diagnosis or treatment in relation to any health problem, and services of the Facilitator do not replace the care of licensed professionals.

MEDICAL DISCLAIMER & CONTRAINDICATIONS

I understand that these Activities may involve strong circular breathing, which can result in dramatic and psychedelic experiences accompanied by strong emotional and physical responses. I understand that I may find the Activities physically, emotionally, or mentally stressful, and that these Activities are not safe under certain medical conditions and not advised for persons with a history of cardiovascular disease or prior heart attack, high blood pressure, use of prescription blood thinners such as Coumadin, epilepsy or seizures, glaucoma, osteoporosis, severe asthma, bipolar disorder, schizophrenia, dissociative disorders, history of significant trauma, and during pregnancy.

I hereby state that I am not pregnant, and if any of the above conditions apply to me, I will advise the Facilitator prior to participation. I understand that the Facilitator is not qualified to evaluate my fitness for involvement in the Activities, and that I am fully responsible for seeking medical help to treat all symptoms that are present before and after the Activities. I hereby state that I am physically and mentally fit to participate in Activities, and understand that it is solely my responsibility to seek professional support after Activities if I feel unstable mentally or emotionally. I knowingly waive any claim I may have against the Releasees for injury or damages that I may sustain as a result of participating in Activities.

RISKS

I understand and acknowledge that the Activities in which I am participating in bear certain known inherent risks that contribute to the unique character of these Activities, and that Facilitator cannot eliminate, alter, or control these inherent risks. “Risks” include, but are not limited to, known and unknown health conditions, inaccessibility to immediate medical attention, risks inherent in breathwork that include, but are not limited to, over-exertion, psychological distress and disorientation, hyperventilation, respiratory alkalosis, muscle spasms, chest pain, numbness, heart attack, death, and injury or death caused by negligence on the part of Participant or other people around Participant.

I hereby expressly and specifically assume the risk of injury or harm, and agree that my involvement in Activities is purely voluntary, and that I elect to participate in spite of the Risks.

CONFIDENTIALITY

I understand that information shared with the Facilitator is privileged communication and strong ethical standards of confidentiality are maintained. I understand that in voluntarily revealing personal information in group Activities, rights of privacy and confidentiality are waived and cannot be guaranteed. I also understand that confidentiality may be waived, without consent, if there is imminent danger to yourself or others, or there is occurrence of child, elder, or dependent adult abuse or neglect.

METHODOLOGY, WARRANTIES, & OUTCOMES

I agree to be open-minded to Facilitator’s methods and partake in Activities and services as proposed and instructed. I understand that Facilitator has made no guarantees as to the outcome of Activities, and that information and testimonials presented before, during, or after Activities do not constitute a warranty of specific outcomes.

LIMITATION OF LIABILITY

By purchasing and participating in Activities, I accept any and all risks, foreseeable or unforeseeable, arising from such transaction. I agree that Facilitator will not be held liable for any damages of any kind resulting or arising from including but not limited to; direct, indirect, incidental, special, negligent, consequential, or exemplary damages happening from participation in Activities or use of materials provided.

INDEMNIFY & HOLD HARMLESS

By clicking “Register,” “Purchase,” “Buy Now,” or any other phrase on the purchase button, entering my credit card information, or otherwise enrolling, electronically, verbally, or otherwise in Activities, I, in my personal name and on behalf of my relatives, heirs, legal representatives, and assigns, agree at all times to release, indemnify and hold harmless Releasees, as well as their affiliates, employees, students, joint venture partners, successors, assignees, and licenses, as applicable, from and against any and all claims, causes of action, damages, liabilities, costs, and expenses, including legal fees and expenses, arising out of or related to Activities. I understand and agree that in entering the enrollment agreement, it does not include the transaction, purchase, or administering of any entheogenic medicines or substances. I understand that this experience is for educational purposes only. I knowingly and freely assume all risks, both known and unknown, even if arising from the negligence of the Releasees or others, and assume full responsibility for my participation in Activities.