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By ticking the box below, I consent to Mirabilis Health using my information to assess my suitability for clinical trials.

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Name *

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Have you ever been diagnosed with any of the following conditions?

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ADHD

Alcohol use disorder

Anorexia nervosa

Anxiety

Autism/Asperger's

Bipolar disorder

Chronic Pain

Cognitive disorders (e.g. Dementia)

Depression

Drug Use Disorder

Heart disease

Hypertension (high blood pressure)

Personality disorder

Psychotic disorder

PTSD

Social phobia

Substance use disorder

None of the above

Other

Do you suspect you have any of the following conditions?

Select all that apply. No diagnosis required.

ADHD

Alcohol use disorder

Anorexia nervosa

Anxiety

Autism/Asperger's

Bipolar disorder

Chronic Pain

Cognitive disorders (e.g. Dementia)

Depression

Drug Use Disorder

Heart disease

Hypertension (high blood pressure)

Personality disorder

Psychotic disorder

PTSD

Social phobia

Substance use disorder

None of the above

Other

Have you received treatment for any of these mental health conditions?

ADHD medication

Anxiety medication

Antidepressants

Antipsychotics

Lithium

Mood stabilisers

None of the above

Other

Are you currently prescribed any of the medication mentioned above?

Yes

No

Do you have a first-degree relative with a history of schizophrenia, schizoaffective disorder or bipolar disorder? *

Yes

No

Have you taken any of the following substances in the last year? *

Psilocybin (magic mushrooms)

Ayahuasca

Mescaline

LSD

DMT

5-MeO-DMT

Peyote

None of the above

How did you hear about us?

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Please specify the preferred time and day for our team to contact you if you are eligible for a follow-up call.

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