Application for Ibogaine Therapy Array

Please answer all questions as accurately as possible, paying special attention to medical and substance use profiles. Incomplete or false information can lead to unintended consequences that may greatly effect your treatment and may lead to serious harm. Keep in mind that most, if not all, of the Ibogaine related complications or deaths have occurred because of heart problems, inaccurate reporting of substance use, and/or use of opiates during or just after treatment. Thank you for your honesty.

A printer-friendly PDF version of this form is also available on our document download page, accessible here.

Please fill out all questions that pertain to your treatment.Current Date: Wednesday, June 28th, 2017
 
* First Name: * Last Name:
* Age: * Gender: * Weight: *Height:
* Street Address:    * City: * State / Province:    * Zip / Postal Code:
* Country:    * Primary Phone: *Cell:    * Email Address:


* Emergency Contact Full Name: * Primary Phone:    Cell:
Doctor Full Name: Primary Phone:
Psychiatrist or Therapist Full Name: Primary Phone:

* Reason for Wanting Ibogaine Therapy:
* Do you have any allergies?: Yes No
If yes, please explain allergies:
* Do you have any specific dietary needs (vegan, diabetic, etc.)?: Yes No
If yes, please explain:
* Do you have experience with psychedelics or visionary plant medicines?: Yes No
If yes, please explain:
* Do you have a passport?: Yes No
* Any pending legal issues?: Yes No
If yes, please explain:
* Do you smoke?: Yes No
If yes, how much and how often do you smoke:
* Do you drink alcohol?: Yes No
If yes, how much and how often do you drink alcohol:
* Are you currently using any other substances?: Yes No
If yes, what kind, how much, and how often do you use other substances:
Where did you grow up?:
What was your family life like?:
Who do you live with now?:
Do they use?: Yes No
What is your educational background?:
Where do you work?:
Have you lost friends or family members to addiction?: Yes No
What is the hardest thing you've ever worked for?:
What do you value most in life?:
What were the four happiest moments of your life?:
What were the four saddest?:
* List medications you are taking & daily dosage:
Please pay special attention to anti-depressants, anti-anxiety medications, benzodiazepines, and QT prolonging medications (if the bottle says to avoid grapefruit while taking your medication, you probably are dealing with a QT prolonger):
* Are you suffering from any emotional or mental conditions?: Yes No
Check All That Apply:  
Bi-Polar Schizophrenia Depression
PTSD 0bsessive / compulsive Eating Disorders Other
If yes, to any of the above, please expand upon or explain:
List history and treatment for any of these conditions:
What are your spiritual beliefs or practices:
How do you handle emotional experiences:
How would you characterize your overall physical condition:
When was the last time you saw a doctor?:
For what reason?:
* Do you have any physical conditions?: Yes No
Check All That Apply:  
Diabetes Stroke Hepatitis A, B, or C Headaches
Bleeding Abdominal pain Stomach problems History of ulcers
Liver problems Slow heart rate History of seizure Jaundice
Urinary problems Thyroid problems Heart problems Heart disease
Low blood pressure Respiratory problems Asthma Loss of menstruation
Painful menstruation Excessive menstruation Cancer Swelling
Fainting Joint pain Numbness Varicose veins
Diarrhea Back problems HIV positive / AIDS Nausea
Shaking Dizzy spells Tuberculosis High blood pressure
Shortness of breath Renal disease Muscle spasm Nerve damage
Heartburn Constipation Obesity  
Please list any surgeries and dates:
How long have you been substance free in the past?:
Have you been to any rehab or treatment programs?: Yes No
If yes, please list details & personal opinion of these experiences:
What has worked to stay drug free?:
What are your goals for recovery?:
Do you have a healthy environment to which to return?: Yes No
Either way, what does this environment look like?:
What do you like to do when you are not using?:
What is your after treatment plan?:
Do you believe people can live happy without substance abuse?: Yes No
Are you willing to give yourself a year to recover?: Yes No
Will you seek therapy before and after treatment?: Yes No
Are you willing to experience some discomfort and restlessness while detoxing?: Yes No
Part of the process of opiate detox may involve extended periods of sleeplessness. Are you prepared for this?: Yes No

Information Usage & Privacy Policy

Your personal information will be held in the strictest of confidence. We do, however, ask that you allow us to use the information you have provided and any data gathered during your treatmentfor research purposes. None of your personal information will be associated with this data. Any information that can be added to the growing knowledge base for ibogaine therapy will lead one step closer to the legitimization and legalization of this very important medicine. Thank you!

* I agree to allow this information be used to further our knowledge of ibogaine therapy: Yes No
NOTE: Indicating a, 'No,' answer to this question will not preclude you from receiving Ibogaine therapy.