MDMA Therapy Registration

Sign up for a session with MDMA

On this page you can fill in your details. We will review your details within one business day and if we can find no contraindications we will schedule a session. Fill in your details without obligation via the form below.

First name

Surname

Age

Place of residence

E-mail

Phone number

Reason MDMA session

Drug use history

Drug use today

Mental disorders

Suicidality/psychosis

I am struggling with suicidal thoughts I had a psychosis

Medicines

Physical ailments

Additional info

I agree to the Terms and Conditions

Truth

I have completed the intake form completely and truthfully

General Terms and Conditions

MDMA THERAPY NETHERLANDS

Register for MDMA session

Sign up for a session with MDMA

MDMA therapy registration