Ibogaine Treatment Application

Primary Emergency Contact
We require the full contact information of at least one person who we can contact in the case of an emergency.
Primary Emergency Contact*
First Last
Relationship*
Phone*
Email*
Secondary Emergency Contact (optional)
Would you like to provide a secondary emergency contact?
- Yes
- No
Secondary Emergency Contact Name
First Last
Relationship
Phone
Email

Treatment Information
Have you ever done ibogaine or iboga treatment before?*
- Yes
- No
Describe your treatment history:*
Please include where, when, for what purpose, and what you felt was the result.
Are you seeking treatment for substance use issues?*
- Yes
- No
Do you drink alcohol in any form or quantity?*
- Yes
- No
How much do you drink and how often?*
Do you smoke tobacco?*
- Yes
- No
How much do you smoke, how often, and for how long?*
Please provide a complete list of all non-prescribed medications and/or street drugs you have used in the past 30 days:
Substance Use Treatment
Describe your substance use:*
Include information such as the substance, method of injestion, dosage, frequency, and how long you have been using.
Psychospiritual Treatment
What are your goals with ibogaine treatment?*
Treatment Date Requested
Date Format: DD slash MM slash YYYY

Mental & Emotional Health
Have you been diagnosed with any mental or emotional conditions?*
- Yes
- No
Please describe these diagnoses:
Have you ever been admitted to a psychiatric hospital or treatment facility for these conditions?
- Yes
- No
Please list approximate dates and detail the condition you were treated for:*
Do you ever struggle with your mental or emotional health?*
- Yes
- No
Please describe this experience:*

Additional Information
Please describe any plans you have in place for after your treatent:
Would you like any additional information about aftercare coaching or residential after programs?
- Yes
- No
Is there anything else you would like to tell us?
How did you hear about us?
Consent for Research
Occasionally, our staff or medical team may collect and present medical information about patients in our care for the purpose of advancing the scientific discourse, publishing or presenting interesting case studies or anomalous treatment events, or preparing statistics, etc. Do you consent to us using any information about your treatment in this way? This does not include your name, or any other personally identifying information.
Do you consent?*
- Yes
- No
- I would like more information before consenting
Confirmation
By typing your name in the box below you certify that all of the information that you have provided here is complete and accurate to the best of your knowledge.
Confirmation*
Type your name in the field below
Name
This field is for validation purposes and should be left unchanged.

Introduction