Ceiba Core Program Application

If you are ready to enroll in Ceiba Recovery's 8-week Core Coaching Program, Journey Recovery, lets get started.

First, please fill out the application form below and share some basic information about where you're at in this moment and what you hope to get out of the program.

Who is this application for?(Required)

I am filling out this form on behalf of a friend or loved one.

I am filling out this form on my own behalf.

Thank you for supporting your loved one or friend in this process, however this form will contain very personal information that we need to collect directly from them. Please have them fill out it on their own, and let them know to put in your email address if you intend to pay.

Personal Information

Name(Required)

What is your current gender identity?(Required)

Check all that apply.

For "Other," please specify:(Required)

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

She/her/hers

He/him/his

They/them/theirs

Other

For "Other," please specify:(Required)

Email(Required)

Where are you located?(Required)

City State / Province / Region Country

What is your preferred mode of contact?

What number will we reach you at?(Required)

For numbers outside of the US and Canada please select Whatsapp, Telegram, or Signal and include the country code.

Can we text you at this number?(Required)

Yes

No

Treatment Information

Do you currently have a treatment booked?(Required)

Yes

No

What is the name of the clinic/provider?(Required)

When do you plan to leave the clinic?(Required)

Have you already had an ibogaine treatment?(Required)

Yes

No

What was the name of the clinic/provider?(Required)

When did you leave the clinic?(Required)

Intentions

Background(Required)

Tell us a bit about your journey around ibogaine so far, either preparing for it or having been through the treatment.

Substances

Please describe and drugs, medications or supplements you are taking. What are they? How much? How often?

Intentions(Required)

What are your main goals with entering into this program? What do you hope to get out of it? Do you have any reservations?

Housekeeping

Who will be paying?(Required)

I am paying for myself.

Someone else is paying for me.

Name of the person paying(Required)

Email of the person paying(Required)

Please make sure this is correct. We will send instructions to this address.

Can we email you?(Required)

We need to contact you at the email address you provided with login information for the program materials, in order to schedule appointments, and for any other issues. Do you consent to this?

Yes

Virtual preparation and aftercare for

Ibogaine Treatment

Personal Information

Treatment Information

Intentions

Housekeeping

Virtual preparation and aftercare for

Ibogaine Treatment

Personal Information

Treatment Information

Intentions

Housekeeping

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