IBOGAINE TREATMENT APPLICATION

Name *

Date *

Age

Address *

Drug of choice *

Emergency contact number

Name *

Do you have a passport? *

YES NO

If no, do you have a government issued ID and birth certificate? *

YES NO

Do you have any pending legal issues? *

YES NO

If yes, short explain

Do you smoke tobacco? *

YES NO

If so, how much do you smoke a day?

Do you drink alcohol?

YES NO

If so, do you have experience any physiological withdrawal, if you, go longer than 3 days without it?

YES NO

Where did you grow up? *

What was your family like? *

Who do you live with now? *

Are they clean?

YES NO

Do you find your current means of making living enjoyable and fulfilling?

YES NO

Have you lost friends and/or family members due to drug addiction?

YES NO

Have you ever tried stopping your drug abuse abruptly (cold turkey)?

YES NO

If yes, how long have you gone without used?

What is the hardest thing you´ve ever worked for? *

What do you value most in your life? *

When, why and where were the happiest moments/months of your life? *

At the end of the spectrum, when, why and where did you experience the saddest of your life? *

What are your spiritual beliefs and practices? *

How do you work through difficult emotional experiences? *

Have you been to any rehab or treatment program?

YES NO

If yes, please list details and personal opinions of these experiences: *

Do you have a healthy environment look like?

YES NO

What are your goals for recovery? *

What do you like to do when you are not using? *

What is your after treatment plan? *

Do you believe people can live happy and clean?

YES NO

Short explain *

Will you seek therapy before and after treatment? .

YES NO

Short explain: *

Are you willing to give yourself a year to recover? …

YES NO

Short explain: *

Part of the process of detox may include extended periods of sleeplessness some discomfort and restlessness. Are you prepared for this? .

YES NO

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!

I agree to allow this information be used to further our knowledge of ibogaine therapy *

YES NO

NOTE: indicating a NO answer to this question will not preclude you from receiving ibogaine therapy.

MEDICAL INFORMATION FOR IBOGAINE TREATMENT

Medical questionnaire

Do you have any drug or food allergies?

YES NO

Explain

Do you have special diet or nutrition needs?

YES NO

Explain

When the last time you saw a doctor and what was the reason?

Do you have any chronical physical condition?

YES NO

Please list any surgeries and dates:

List all medications you are currently taking, include over-the-counter drugs and herbal supplements:

MEDICATION

DOSAGE

REASON

MEDICATION

DOSAGE

REASON

MEDICATION

DOSAGE

REASON

MEDICATION

DOSAGE

REASON

Are you suffering from any emotional or mental conditions?

YES NO

If yes to any of the above please expand upon or explain:

List history and treatment for any of these conditions:

How would you characterize your overall physical condition? *