333-333-5050 Client Information Form (1) A client must review and complete a client information form in coordination with a facilitator prior to participating in an administration session. This requirement must be satisfied by using the designated form published by the Oregon Health Authority (Authority) on its website. (2) A facilitator must provide a client information form in other languages or accessible formats upon a client’s request. If a facilitator is unable to provide a translated or accessible client information form upon a client’s request, they may not conduct an administration session with the client. (3) The client information form must include the following questions, and a client must answer each question by indicating “yes” or “no”: (a) Have you taken the prescription drug Lithium in the last 30 days? (b) Are you currently being treated by a medical, clinical or other healthcare provider for a medical, mental health, or behavioral health condition? (c) Have you ever had an allergic reaction to consuming mushrooms or other fungi? (d) Are you currently taking any prescription medications, non-prescription medication or nutritional supplements that might need to be consumed during an administration session? (e) Will you require assistance from an interpreter during an administration session? (f) Will you require assistance from a client support person for catheter, ostomy, or toileting assistance, ambulation or transfer mobility support, or medical device assistance during the administration session? (g) Will you require assistance from a client support person for augmentative and alternative communication (AAC) device support or assistive listening device support during the administration session? (h) Are you having thoughts of causing harm, or wanting to cause harm, to self or others? (i) Do you have a history of causing harm, or wanting to cause harm, to self or others? (j) Have you ever been diagnosed with active psychosis or treated for active psychosis? (k) Are you pregnant or feeding with breast milk? (l) Do you require any assistive mobility devices? (m) Will you require assistance to consume psilocybin products? (n) Would you like to share any other conditions, sensitivities or health concerns with your facilitator? (4) The client information form must include the following questions, and a client may provide a narrative answer to these questions. (a) Would you like to share anything about your medical history, including current prescription medications, non-prescription medication or nutritional supplements, that you feel would be helpful for an administration session? (b) Would you like to share anything about your mental health history, including traumatic experiences that you feel would be helpful for an administration session? (c) Would you like to share anything about specific behaviors, internal or external stimuli (“triggers”) that could cause you to be uncomfortable during an administration session? (d) Would you like to share anything about your history of substance use, including current substance use, that you feel would be helpful for an administration session? (e) Would you like to share any past experiences with psychedelics or altered states of consciousness? (f) Would you like to share any information about your relationships, your living situation, or your educational or work environment that may be affected by your administration session or may require additional safety or support planning? (5) A facilitator must evaluate the answers to questions listed in section (3) of this rule to determine whether the client should participate in an administration session. (a) If a client answers yes to question (3)(a), the client may not participate in an administration session. (b) If a client answers yes to question (3)(b), a facilitator shall encourage the client to consult a medical, clinical or other healthcare provider regarding the risk of consuming psilocybin. (c) If a client answers yes to question (3)(c), the client should be encouraged to consume an alternative psilocybin product rather than whole fungi or homogenized fungi during the administration session. (d) If a client answers yes to question (3)(d), a facilitator should encourage the client to schedule their administration session at a time that allows them to participate without taking prescription medications, non-prescription medication or nutritional supplements. A facilitator should also encourage the client to consult with a pharmacist or medical, clinical or other healthcare provider regarding contraindications. If the client will take prescription medications, non-prescription medication or nutritional supplements during an administration session, the client and facilitator must work together to identify whether the client will be able to administer the prescription medications, non-prescription medication or nutritional supplements themselves. If the client is unable to administer the prescription medications, non-prescription medication or nutritional supplements themselves, the client must identify a client support person who will be available to administer the prescription medications, non-prescription medication or nutritional supplements when required and complete a written medication plan in a form and manner prescribed by the Authority . (e) If a client answers yes to question (3)(e), the client and facilitator must work together to identify an appropriate interpreter who will be present in person or virtually during the client’s administration session. (f) If a client answers yes to question (3)(f), the client and facilitator must work together to create a written assistance and medical device plan in a form and manner prescribed by the Authority. (A) If the client requires a medical device, the plan must describe the required medical device and indicate whether the client will be able to use the medical device without assistance. If the client is unable to use the medical device without assistance, the plan must identify a client support person who will be available to assist the client with their medical device when required. (B) If the client requires assistance with catheter, ostomy, or toileting assistance, ambulation or transfer mobility support, the plan must identify the type of assistance required and a client support person who will be available to assist the client. (g) If a client answers yes to question (3)(g), the client and facilitator must work together to identify an appropriate client support person who will be present during the client’s administration session to assist with the client’s alternative communication device support or assistive listening device support during the administration session. (h) If a client answers yes to question (3)(h), the client may not participate in an administration session. (i) If a client answers yes to question (3)(i), a facilitator shall encourage the client to consult with a medical or clinical provider regarding the risk of consuming psilocybin. (j) If a client answers yes to question (3)(j), the client may not participate in an administration session. (k) If a client answers yes to question (3)(k), the facilitator must inform the client that the risks of consuming psilocybin while pregnant or feeding with breast milk are unknown. (l) If a client answers yes to question (3)(l), the client and facilitator must work together to create a written plan that describes how the client will safely exit the service center in the event that an emergency occurs during their administration session. (m) If a client answers yes to question (3)(m), the client and facilitator must work together to identify an appropriate client support person who will be present to assist the client with consuming psilocybin products during their administration session. (n) If a client answers yes to question (3)(n), the client and facilitator must work with the client to create a written plan that describes how the facilitator will take reasonable steps to accommodate the conditions, sensitivities or health concerns identified by the client. For example, if a client has a compromised immune system, the written plan will describe efforts to prevent the transmission of viruses and bacteria. (6) All client records, including any copies of client records, described by this rule must be stored at the service center where the client participates or intends to participate in an administration session as required by OAR 333-333-4820. Statutory/Other Authority: ORS 475A.235 & ORS 475A.340 Statutes/Other Implemented: ORS 475A.340 History: PH 82-2024, amend filed 11/22/2024, effective 01/01/2025 PH 58-2023, amend filed 12/21/2023, effective 01/01/2024 PH 206-2022, adopt filed 12/27/2022, effective 12/27/2022