Treatment Application

Personal Information
Full Name*
Birthday*
Where do you live?*
City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Phone*
Do you have a valid passport?*
- Yes
- 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*
Emergency Contact Phone*
Emergency Contact Phone*

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.

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.

Personal Information

Drug/Medication	Dosage	Reason

Supplement	Dosage	Reason