Application Application Form Please note that EVERY field must be filled out for you to be able to submit this form.Name* First Last Age*Weight*Height*Gender*Phone*Email* Emergency contact info*Reason for seeking treatment*How is your physical health?*Are you currently under a physician's care? Please describe.*Please list all medications and supplements you are taking with dosage and frequency.*Please check all aliments that you have:* High blood pressure Low blood pressure Headaches History of ulcers Circulatory problems Constipation Cancer Nausea Heart disease Stomach problems Breathing difficulty Digestive problems Wounds/abcesses Dizziness/fainting Hepatitis A, B or C History of seizures Asthma Diabetes Diarrhea Anemia Back injury None listed here Please describe any conditions checked above*Please list all surgeries and dates*Please list any allergies*Pleae list any dietary restrictions*Do you have any experience with plant medicines or psychedelics?*What substances are you using?*What quantity and frequency?*Do you drink alcohol? If yes, how much and how often? What form?*Do you smoke or chew tobacco? If yes, how much?*Do you currently have any mental or emotional conditions? Please elaborate:*Do you have a history of mental or emotional conditons? if yes, please explain and list any treatments:*What are your spiritual belief and practices, if any?*What were your spiritual beliefs and practices growing up, if any?*How did you first find out about Iboga?*Have you independently studied Iboga? If so, did anything in particular stand out?*Where did you grow up?*How would you describe your childhood and early family life?*What is your current home life like? Who do you live with?*Are the people you live with clean and supportive?*What is your occupation?*Please describe a typical day?*How do you usually handle emotional events and experiences?*What great disappointments have you had in your life?*What great joys have you had in your life?*What do you take pride in?*How long have you been clean in the past? How did you do it?*What do you enjoy doing when you are not using?*What are your plans post treatment? Please be as detailed as possible.*Please describe your support system (friends, family, therapists, support groups, etc.)*Are you willing to experience discomfort while detoxing, including nausea, restlessness and emotional distress?*Are you willing to experience periods of insomnia post treatment?*Do you have any pending legal issues? If yes, please explain.*Do you have a passport?* Yes No Your personal information will be held in total confidence. If you agree, we would like to use general data about your session (excluding all identifying details) to further Iboga knowledge and research. I agree to allow this information to be used to further knowledge about Iboga.* Yes No Please note that your choice in no way affects or determines whether or not you will receive treatment.CommentsThis field is for validation purposes and should be left unchanged.