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Email
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Phone
*
Phone
*
Do you have a valid passport?
*
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No
Do you have a valid government issued photo ID and a birth certificate?
*
Yes
No
Do you have any pending legal issues?
*
Yes
No
Please explain:
*
Emergency Contact
Emergency Contact Full Name
*
Emergency Contact Email
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Emergency Contact Phone
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Emergency Contact Phone
*
Personal Background
Where did you grow up?
*
What was your family like?
*
Is substance use/addiction part of your family history?
*
Yes
No
Can you describe this history?
*
Have you lost friends and/or family members due to drug addiction?
*
Yes
No
How do you currenty support yourself? / How are you currently supported?
What is the hardest thing you ́ve ever worked for?
What do you value most in your life?
Do you have any spiritual beliefs and practices? Describe:
*
Recovery
What are your goals for recovery?
*
Describe your previous experiences with detox, either cold turkey or medication managed, as well as treatment programs.
*
What has worked in the past to support your recovery?
*
How long have you gone in the past maintaining sobriety?
*
How do you work through difficult emotional experiences?
*
Are you willing to give yourself a year to recover?
*
Yes
No
What are your plans for after your ibogaine treatment?
*
Our in-house therapist has created a useful resource of
post-treatment options
that include coaching, inpatient aftercare, and various kinds of alternative recovery group.
Part of the process of detox may include extended periods of sleeplessness some discomfort and restlessness. Are you prepared for this?
*
Yes
No
I'd like to know more.
Medical Information
Do you have any drug or food allergies?
*
Yes
No
Please describe:
*
Do you have special diet or nutrition needs?
*
Yes
No
Please describe:
*
When the last time you saw a doctor and what was the reason?
*
Please check any conditions that you experience or have been diagnosed with:
Diabetes
Headaches
Stomach problems
Slow heart rate
Urinary problems
Heart disease
Asthma
Excessive menstruation
Fainting
Varicose veins
HIV
Dizzy spells
Nerve damage
Shortness of breath
Stroke
Bleeding
History of ulcers
History of seizures
Thyroid problems
Low blood pressure
Loss of menstruation
Cancer
Joint pain
Diarrhea
Nausea
Tuberculosis
Heartburn
Renal disease
Abdominal pain
Liver problems
Jaundice
Heart problems
Respiratory problems
Painful menstruation
Swelling
Numbness
Back problems
Shaking
High blood pressure
Muscle spasms
Constipation
Hepatitis A, B, or C
Please list any surgeries and dates:
Have you ever, or are you currently, struggling with emotional or mental conditions?
*
Yes
No
Please check any diagnosis that apply:
*
Depression
Bipolar
PTSD
Schizophrenia
Obsessive/compulsive
Eating disorders
Other
If "Other", please describe:
*
Please explain, and list any history of treatment for any of these emotional or mental conditions:
*
Substance Use
Do you smoke tobacco?
*
Yes
No
How much do you smoke per day?
*
Do you drink alcohol?
*
Yes
No
Please describe how much you drink per day/week/or month:
*
Do you take any other drugs or medications of any kind?
*
Yes
No
Please list all of them here:
*
Drug/Medication
Dosage
Reason
Do you take any neutriceutical or herbal supplements?
*
Yes
No
Please list all of them here:
*
Supplement
Dosage
Reason
Information usage and 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 provide and any data gathered during your treatment for research purposes. None of the personal information will be associated this data. Any information that can be added to the growing knowledge based for ibogaine therapy will lead us one step closer to the legitimization and legalization of this very important medicine. Thank you!
NOTE: indicating a "No" answer to this question will not preclude you from receiving ibogaine therapy.
I agree to allow this information be used to further our knowledge of ibogaine therapy.
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