Ibogaine Application Form

"*" indicates required fields

SERIOUS ENQUIRIES ONLY. Expect us to call for pre-consultation info.

Please note that EVERY field must be filled out for you to be able to submit this form.

Please complete this application ONLY if you are fully committed to participating in this treatment program. We contact you within 24 hours to arrange a telephone call and it is important you be available during that timeframe. Thank you for being genuinely ready and respecting our time and resources and please click the box below to indicate you understand and agree:*

I understand and agree

Name*

First Last

Age*

Weight*

Height*

Gender*

What city, state/province and country do you live in?*

Profession*

Phone*

Email*

Emergency contact info*

General Business

Do you have any pending legal issues? If yes, please explain.*

Do you have a passport?*

Yes

Where would you prefer treatment?*

Canada

Mexico

How are you financing or able to afford this kind of private treatment program? *

Health

How is your physical health?*

Are you currently under a physician's care? Please describe.*

Please list all medications and supplements you are taking with dosage, form and frequency along with how long have you been taking it?*

Please check all aliments that you have:*

High blood pressure

Low blood pressure

Headaches

History of ulcers

Circulatory problems

Constipation

Cancer

Nausea

Heart disease

Stomach problems

Breathing difficulty

Digestive problems

Wounds/abcesses

Dizziness/fainting

Hepatitis A, B or C

History of seizures

Asthma

Diabetes

Diarrhea

Anemia

Back injury

None listed here

Please describe any conditions checked above*

Please list all surgeries and dates*

Please list any allergies*

Please list any dietary restrictions*

Do you rely on any adaptive equipment or medical devices? If yes, please describe.*

Plant Medicines

Do you have any experience with plant medicines or psychedelics?*

How did you first find out about Ibogaine?*

Have you independently studied Ibogaine? If so, did anything in particular stand out?*

How did you learn about us?*

Facebook

Instagram

Google ads

Google reviews

A directory

Other

If you checked A directory or Other above, please elaborate here (state what directory, if from a friend, etc:

Treatment Applying for:*

Ibogaine Therapy

5MEO Session

Psilocybin therapy

Condition Applying for:*

Addiction

Depression

PTSD

Other - tell us more on the next page

Reason for seeking treatment*

Mental Health & Substances

Do you currently have any mental or emotional conditions? Please elaborate:*

Do you have a history of mental or emotional conditons? if yes, please explain and list any treatments:*

Describe your history of drug and alcohol use,eating disorders or other addictive behaviours starting with the original onset to present?*

What substances are you currently using?*

What quantity and frequency?*

Do you drink alcohol? If yes, how much and how often? What form?*

Do you smoke or chew tobacco? If yes, how much?*

Do you take caffeine? If yes, what is your daily consumption? *

Childhood

Where did you grow up?*

How would you describe your childhood and early family life?*

What were your spiritual beliefs and practices growing up, if any?*

What great disappointments have you had in your life?*

What great joys have you had in your life?*

Daily Life

Please describe a typical day?*

What do you take pride in?*

How do you usually handle emotional events and experiences?*

What are your spiritual belief and practices, if any?*

What do you enjoy doing when you are not using substances?*

Support in Recovery

What is your current home life like? Who do you live with?*

Are the people you live with drug & alcohol-free and supportive?*

How long have you been drug-free in the past? How did you do it?*

Briefly describe any rehab programs you have experienced:*

Aftercare

Please describe your support system (friends, family, therapists, support groups, etc.)*

What is your after treatment plan? Please be as detailed as possible.*

Are you willing to give yourself a period of time (3-12 months) to focus on recovery and integrate your experience?*

Are you willing to experience discomfort while detoxing, including nausea, restlessness and emotional distress?*

Are you willing to experience periods of insomnia post treatment?*

Would you like a referral for an ibogaine informed therapist?*

Yes

I agree to receiving further info and updates from the monthly newsletter (you can unsubscribe any time.)*

Yes

Your personal information will be held in total confidence. If you agree, we would like to use general data about your session (excluding all identifying details) to further Iboga knowledge and research. I agree to allow this information to be used to further knowledge about Iboga.*

Please note that your choice in no way affects or determines whether or not you will receive treatment.

Yes

Phone

This field is for validation purposes and should be left unchanged.