Ibogaine Treatment Application

Ibogaine-Assisted Recovery

Treatment & Aftercare Application

Step 1 of 5 - Personal

If you are ready to apply for ibogaine treatment and/or to explore aftercare programs, lets get started.

First, please fill out the application form below so we can provide the most accurate information possible about suitable options.

Personal Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

What is your current gender identity?(Required)

Check all that apply.

Female

Male

Transgender Female/Transwoman/MTF

Transgender Male/Transman/FTM

Gender Queer

Other

Decline to answer

For "Other," please specify:(Required)

What gender were you assigned at birth?(Required)

Male

Female

Other

Decline to answer

For "Other," please specify:(Required)

What pronouns do you prefer that we use when talking about you?(Required)

She/her/hers

He/him/his

They/them/theirs

Other

For "Other," please specify:(Required)

Where do you live?

City State / Province / Region Country

Email(Required)

Phone(Required)

Do you have a current, valid passport?(Required)

Note: American residents arriving via San Diego only required a state-issued ID (not necessarily a passport) to return to the US.

Yes

Do you have any pending legal issues?

Yes

Please describe these legal issues briefly? (especially: probation, federal charges, etc.)(Required)

Emergency Contact

Emergency contact's full name(Required)

First Last

Relationship to you(Required)

Emergency contact's email(Required)

Emergency contact's phone(Required)

Ibogaine Treatment

Please select the primary reason for your application:(Required)

Detoxification from alcohol or drugs

Psychospiritual

Neurodegenerative disorders

Ibogaine aftercare only

Please select any recovery options that you are interested in:

We strongly encourage you to consider additional recovery support of some kind when looking to ibogaine for detoxification.

Inpatient aftercare (4-6 weeks)

Lower intensity virtual aftercare (8 weeks)

Private recovery coach (variable)

Recovery groups (non-traditional)

Recovery groups (traditional)

Please describe why you are seeking ibogaine now:

Have you previously sought any kind of medical or psychological treatment for these same reasons?

Yes

Please describe:

Are you currently under the care of a therapist or psychiatrist?

Yes, regularly

Yes, temporarily

Please describe:

Do you currently have any kind of psychological or spiritual support?

Yes

A little

Please describe:

Do you have a TBI (traumatic brain injury) or a history of either combat- or blast-related injury to head, or violent blows or jolts to head?(Required)

Yes

Has any object ever shattered you skull or penetrated your brain? (ex. a metal bullet, shrapnel, etc.)(Required)

Yes

Medical Information

Are you currently, or in the past month, have you been a participant in a clinical trial?(Required)

Yes

Please describe:(Required)

Height(Required)

Weight (please indicate whether you're referring to lbs or kg)(Required)

When was the last time you had a full general physical exam?

Are you able to bear children?(Required)

Yes

Please describe if you have had a historectomy, passed menopause, hysterectomy, have had other sterilization surgery, or other reason:(Required)

Do you have any food allergies / intollerances?

Yes

Please describe:(Required)

Do you have any special dietary or nutritional needs?

Yes

Please describe:(Required)

Do you have any drug/medication allergies / intollerances?

Yes

Please describe:(Required)

Have you had COVID-19?(Required)

Yes

Unsure

Have you been vaccinated for COVID-19?(Required)

Yes

Please describe your COVID-19 symptoms, and if/when/where you were hospitalized:(Required)

Please describe why you believe you may have had COVID-19:(Required)

Please describe which COVID-19 vaccine you received, as well as when and how many shots, including any boosters:(Required)

In the last 3 years have you been diagnosed with any significant physical or mental disorder?(Required)

Yes

Please describe:(Required)

Please check any conditions that you experience or have been diagnosed with:

Diabetes

Headaches

Stomach problems

Urinary problems

Heart disease

Asthma

Excessive menstruation

Fainting

Varicose veins

HIV

Dizzy spells

Nerve damage

Shortness of breath

Stroke

Bleeding

History of ulcers

Thyroid problems

Low blood pressure

Loss of menstruation

Cancer

Joint pain

Diarrhea

Nausea

Tuberculosis

Heartburn

Renal disease

Abdominal pain

Jaundice

Respiratory problems

Painful menstruation

Swelling

Numbness

Back problems

Shaking

High blood pressure

Muscle spasms

Constipation

Hepatitis A, B, or C

Do you have a history of heart, liver or kidney problems?(Required)

Yes

Please describe and list any diagnosis:(Required)

Do you have a significant neurological disorder?(Required)

Examples: Parkinson's, epilepsy, dementia, history of strokes or brain tumors, etc.

Yes

Please describe:(Required)

Do you have a cardiac pacemaker, internal defibrillator, infusion pump or other metallic device implant anywhere in your body?(Required)

Yes

Do you have any metallic hardware implanted anywhere in your body, including from spinal and orthopedic surgeries?(Required)

Yes

Please describe the nature of these implants and their function:(Required)

Please list any surgeries you have had, and the dates:

Have you ever been hospitalized for any reason?

Yes

Please describe:(Required)

Include: When? For what reason? For how long?

Psychiatric Information

Please select any of the following that you experience:

Claustrophobia

Vertigo

Motion sickness

Sleep paralysis

Have you ever, or are you currently, struggling with emotional or mental conditions?

Yes

Please describe:(Required)

Where necessary, clarify current and past experiences.

Have you ever been admitted overnight to a psychiatric or substance abuse facility, even if it was just for one day?

Yes

Please describe:(Required)

Include: When? For what reason? For how long?

Please check any diagnosis you have been given:

Depression

Bipolar

PTSD

Schizophrenia

Schizo-effective disorder

Obsessive/compulsive

Eating disorders

Substance use disorder

History of other psychotic symptoms

Other

Please clarify more about this diagnosis:(Required)

Do you, or have you ever, experienced any suidical ideation or intents?(Required)

Yes

Please describe:(Required)

Drug & Medication Information

Do you smoke/chew tobacco?

Yes

How much per day?

Do you drink alcohol?(Required)

Yes

How much per day/week/month?(Required)

Can you go 7 days without any alcohol intake without symptoms of withdrawal?(Required)

Please be sure of this. We ask all clients to refrain from alcohol and any illicit drug use for two weeks prior to ibogaine administration. Please be honest, as honesty will not exclude you from this study and we will assist in helping you stop any behavior which might disqualify you from the study.

Yes

Not sure

Are you currently taking any drugs or medications?(Required)

It is important that you answer this question fully, even if it includes illicit drugs. This will not necessarily disqualify you from treatment.

Yes

Please list all drugs and medications you are currently taking:(Required)

Drug/Medication

Dosage/Frequency

When did you start?

Have you taken any drugs or medications in the last 3 months?(Required)

Again it is important that you answer this question fully, even if it includes illicit drugs. This will not necessarily disqualify you from treatment.

Yes

Please list all of them here:(Required)

Drug/Medication

Dosage/Frequency

When did you start/stop?

Are you exposed to fentanyl at all?(Required)

Clinics test for fentanyl when you arrive. Having fentanyl present in your system may extend your treatment and increase the cost of your stay.

I take fentanyl or fentanyl analogs

There may be fentanyl in what I'm taking

I'm certain there is not fentanyl in what I'm using

Are you currently taking any neutriceutical or herbal supplements?(Required)

Yes

Please list all of them here:(Required)

Supplement

Dosage/Frequency

When did you start/stop?

Would you like to receive information about participating in an ibogaine-related research study?

There is no compensation. Deciding to participate or not will have no impact on the care you receive.

Yes

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.

NOTE: If you do not click "I consent" below this will not preclude you from ibogaine treatment. Not consenting will have no impact on the care you receive.

I consent

How did you hear about us?

Ibogaine-Assisted Recovery

Personal Information

Emergency Contact

Ibogaine Treatment

Medical Information

Psychiatric Information

Drug & Medication Information

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