This form is for clients of Oregon’s Psilocybin Services program to share their experiences within the nation’s first state-regulated psilocybin therapy program.

This form will help the Healing Advocacy Fund understand on-the-ground experiences to better inform future programmatic changes, and share narratives about the program that help the public understand the risks and benefits of psilocybin therapy.

This form is not meant to be a formal complaint system. Responses will be used, at our discretion, for communications and marketing purposes regarding the psilocybin therapy program. If you have a formal complaint you would like investigated, please file it with OHA. Complaints are subject to public disclosure under Oregon's Public Records Law. If you are concerned about your privacy or safety, OPS will make effort to keep your identity confidential to the extent permitted by law.

Healing Advocacy Fund Consent and Release Language

I grant the Healing Advocacy Fund and its affiliates the right to use, publish, and distribute my name and my story for the purposes of education, advocacy, publicity, communications, marketing and promotion in all forms of media, including online platforms.

I understand and agree that:

1. My name and story may be used in whole or in part in all forms of media without time restriction.

2. My name and story may be edited, altered, or published for purposes of providing information about the psilocybin therapy program, psilocybin therapy, the Healing Advocacy Fund and its programs.

3. I did not receive and will not receive compensation from the Healing Advocacy Fund for use of my name or story.

4. I am aware that psilocybin remains illegal under federal law and that disclosure of my name and story could expose me to legal risk and harm.

5. The Healing Advocacy Fund is not providing me with legal assurance, legal representation, or legal advice.

6. This consent is voluntary, and I release the Healing Advocacy Fund from any claims, demands, or liabilities arising out of or in connection with the use of my name and my story, including but not limited to any claims for invasion of privacy, appropriation of likeness, or defamation.

In consenting to this release, I acknowledge and represent that I have read, understood and provided my consent voluntarily; I am an adult, and fully competent; and I fully understand the contents thereof.