Study Intake Form

Name(Required)

Full Name

Email(Required)

Phone(Required)

Current Age(Required)

Please enter a number from 21 to 64.

Gender(Required)

Male

Female

Other

Ethnicity(Required)

Height (specify ft or m)(Required)

Weight (specify kg or lb)(Required)

Country of Birth(Required)

Country

Country of Residence(Required)

Country

Drugs/Medications/Supplements

Please list all current drug and/or medications and the dosages at which you take them, whether over the counter, prescribed, or illicit.

Substance

Dosage

Frequency

Medical Conditions

Please indicate any that apply:

Please describe.

Psychiatric Conditions(Required)

Have you ever been diagnosed with a psychiatric condition?

Yes

No

Please describe.

Psychedelic Substances

Have you ever used any of the following substances? Please select all that apply.

Psychedelic Experience(Required)

Which statement best describes your experience with psychedelic substances?

None

Very little

Moderate

Extensive

Have you ever taken iboga or ibogaine before?(Required)

Yes

No

What is your intention in seeking ibogaine therapy?(Required)

Do you have any specific hopes or expectations for your ibogaine experience?(Required)

When are you scheduled to leave the United States to take ibogaine?(Required)

When do you expect to return home after your experience?(Required)

Exploring the Oneirogenic Experience

Study Intake Form

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