Application Form

Personal Information

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Country *

Citizenship *

Phone Number *

Cell Number *

Email *

ID/Passport Number *

Weight *

Height *

Date of Birth *

Marital Status *

Dependants *

Primary Physician Name *

Physician Phone Number *

Medical Aid *

Medical Aid Information *

Emergency Contact Details

Name *

First

Last

Relationship *

Address *

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Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Cell Number *

Drug History

What substance(s) are you seeking detoxification from? Please list amount or dosage, what form(s) you take it in and how often you use: *

Are any of these substances prescribed to you by a doctor or therapist? If so please provide details: *

Have you ever been abstinent from the substance/s you are seeking to detoxify from? If so, how long did this period of time last? *

Do you drink alcohol? (If yes, please provide details below when asked about other substances that you use) *

Please describe your usual withdrawal symptoms (if any): *

If so, what did you find helpful in maintaining abstinence? *

Do you smoke tobacco? *

Do you use Cannabis? (Please provide details about your cannabis use below when asked about other substances. Please also provide details about what forms you use it in, such as whether you smoke it, eat it etc... Please be specific.) *

Are you using any other substances? If so, please list amount or dosage, what form you take it in and how often (Please include all other substances including alcohol or any other legal or illegal substances): *

Please provide a detailed chronological history of your substance use (Please list dates and details of your use. ie: 1990 - 1994 injected heroin twice a day and smoked crack 3 -5 times on weekends): *

Please list other detox or treatment programs you have participated in, and tell us why they did or didn't work for you: *

Have you participated in Narcotics Anonymous or Alcoholics Anonymous? *

Have you ever tried ibogaine therapy before? *

If so, please provide an account of your ibogaine therapy and the outcome: *

Do you participate in any counseling or other forms of therapy or support groups? If so, please provide details: *

Do you have a sex or porn addiction? *

Do you have a video game addiction? *

Do you have an eating disorder? *

Please describe your plans for aftercare. List any aftercare options which appeal to you: *

Medical History

If you answered yes to any of the preceding questions, please provide details here: *

Do you or your family have any history of cardiac abnormalities, heart attack or stroke? If so, please provide details. *

Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If so, Please provide details. *

Please list any medications you are presently taking or have taken in the past 6 months. Please list amount or dosage and how often (Please include all medications whether they are prescribed to you or not): *

Are you taking any steroids or hormones such as HGH (Human Growth Hormone)? If so, please list amount or doseage and how often: *

Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking. Please list amount or dosage and how often. *

Please list any depo injections or other injections that you have been given recently or regularly: *

Do you have a chronic pain issue? If so, please describe (Please tell us about the source of your pain and what you do to manage it): *

If you have chronic pain please describe the severity by choosing on a scale from 1 to 10 (1 represents hardly any pain at all, while 10 represents the worst imaginable pain). *

Please list all prior surgeries or operations including dates: *

Do you have any allergies to foods, medications, herbs or drugs? If so, please describe: *

Have you ever been diagnosed with or do you have any psychiatric conditions? Please describe eg. Borderline Personality Disorder, Bi Polar Disorder, Major Depression, Uncontrollable Anxiety, Obsessive-Compulsive Disorder, Schizophrenia, Panic Disorder. *

Are you currently undergoing care for a psychiatric condition? Please describe (If yes, please also list any medications you are taking for this): *

Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)? *

Have you ever had a Holter monitor heart test (A heart test where you wear a monitor for 24 hours)? *

Metabolism

Would you consider your metabolism of substances/drugs to be normal, high or low? *

When taking substances do you find you usually need more or less than most people do for an effect from a regular dose? *

Have you ever taken a substance/drug that had little or no effect? If so please describe. *

Have you ever had an adverse or allergic reaction to any medications or drugs? If so please describe what it was and the dosage/s taken. *

Have you ever had a CYP2D6 metabolism test? *

If so, please tell us what your CYP2D6 metabolism phenotype is: *

If you are HIV Positive, Are you using Anti-Viral Medication ? *

Tell Us About Yourself

Please describe any goals you have, what kinds of things motivate you in your recovery? *

Please describe what you do in your career, work or study: *

Please describe what your social support network is like (such as family, friends, co-workers): *

Do you have any spiritual practices or beliefs? *

Please describe your living environment, do you consider it to be healthy or unhealthy? *

Please describe your eating habits and your relationship to nutrition: *

Do you feel like you could use some counseling in learning more about nutrition? *

Are you a vegetarian? *

Have you ever taken a psychedelic or entheogen? If so, please describe: *

If so, have you had any negative experiences or reactions to these? Please describe: *

COVID-19 Screening Questionnaire

Do you currently have a cough? *

Yes No

Do you experience shortness of breath? *

Yes No

Do you experience chest pains? *

Yes No

Do you currently have a sore throat? *

Yes No

Have you recently loss your sense of smell? *

Yes No

Have you recently noticed an alteration in your sense of taste? *

Yes No

Are you experiencing a high fever? *

Yes No

Are you experiencing any muscle pain? *

Yes No

Have you been experiencing any diarrhoea lately? *

Yes No

Have you been in close contact with anyone who tested positive, or is suspected to have COVID-19? If yes, please provide details. *

Yes No

Comment *

Have you been in contact with anyone where confirmed cases of COVID-19 have been established at their institution/place of work/place of worship? If yes, please provide the details. *

Yes No

Comment *

Almost Done!

Please tell us what your intentions and/or expectations are for your ibogaine therapy: *

Is there anything else you would like to tell us about yourself? *