Cannabis-Assisted Psychedelic Therapy (CAPT) Client Feedback Form for Credentialing

I hope the treatment was significant. I would appreciate your feedback. This feedback will also be forwarded to my teachers for the benefit of my professional training, but will not be forwarded to another person without your knowledge and express consent

If it is easier for you to answer in Hebrew, please use this link:

    Thank you for completing this form and providing feedback to your facilitator about your psychedelic cannabis experience. Your experience may be anonymously reviewed in a group supervision session to support the professional development of your guide. Any identifying information will remain confidential. If you wish to ask questions about, or provide feedback regarding this process, or your facilitator, you can email us at [email protected] . Your feedback is greatly appreciated.

    Client Feedback Form
    1. Describe the type and amount of cannabis product used (flower, oil, edible etc)
    Please Answer the following Yes or No questions - briefly discuss if relevant
    1. I received a disclosure form and psychedelic safety assessment. YN
    2. I was required to have a ride home. YN
    3. YN
    4. YN
    Please rate your experience from 1 to 5, with 1 being Strongly Disagree/Unsatisfied to 5 being Strongly Agree/Very Satisfied.
    1. I felt prepared by the facilitator for the experience. 2. I felt supported by the facilitator during the experience. 3. I felt supported by the facilitator after the experience. 4. I felt safe with my facilitator. 5. The setting for the experience was great. 6. The guided meditation was great. 7. Interventions and guidance was helpful. 8. The music selection was enjoyable and/or helpful to my process. 9. My experience was somatic (I experienced shaking, spontaneous movement, contractions or physical releases) 10. My experience had inner visuals (it was dreamlike, imaginal, or I experienced synesthesia between visual sensations and music/physical sensations?) 11. I found the experience overall very helpful/meaningful. 12. I would recommend this service to others.

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