Essential Deep One Day Lab Application

Please complete the application in its entirety. If you have any questions about the application, please email jesse@atradelast.com.

Name

First Name

Last Name

Choose your selected lab date

Email Address

Phone Number

Do you receive text messages?

Home Address

Age

Emergency Contact Name

Emergency Contact Cell Phone Number

Food Allergies or Restrictions

Were you referred to the Lab by anyone? If so, would you be comfortable sharing their name?

Relationship Status

Describe Sexual Identity

Family members (as you define it) living with you

Family members (as you define it) not living with you

Describe spiritual or religious background if any

Describe any relevant personal development

Are there any unique circumstances you feel we need to be aware of before the lab?

Do you have any history of hospitalization for mental health? If yes, please describe?

Why is this lab of interest to you?

By submitting this application, you acknowledging the following: It is important for you to know there are risks involved in labs, counseling and treatment. For example, some people experience an increase in stress, particularly during the early stages of labs, counseling and treatment. In some cases, discussing long-standing, unresolved problems can seem to aggravate rather than help the problem. These are natural occurrences and you should be aware of them. Uncomfortable levels of feelings may also increase such as sadness, guilt, frustration, and loneliness. During the lab, no specific outcomes can be guaranteed. The lab is not therapy or consultation however those services can be provided at an additional cost. There is no guarantee of confidentiality but will do our best to ensure emotional safety during the lab and request all participants to adhere to confidentiality. We kindly recommend you abstain from chemicals 24 hours prior to lab. This lab is not affiliated with James Grey Ventures, LLC or Kate Goodell Therapy, PLLC and all entities are considered separate. Initial Below: