Application

Thank you for your interest in our program. Our next availability is July 1, 2013. We do have a waiting list. Please keep that in mind if you are looking for an immediate reply. In order to be considered, we ask that you fill out the application below. We are most grateful for your honesty with this personal information, and will keep it confidential.

First Name : Last Name:

Age: Gender: Weight:

Street Address: City: State:

Zip Code: Country:

Primary Phone: Cell: Email:

Emergency Contact Full Name:

Primary Phone: Cell:

Doctor Full Name: Phone:

Psychiatrist or Therapist Full Name: Phone:

Reasons for wanting therapy:
Do you have any allergies?	Yes No
If yes, please explain your allergies:
Do you have any specific dietary needs? (vegan, diabetic, etc.)	Yes No
If yes, please explain:
Do you have any experience with psychedelics or visionary plant medicines?	Yes No
If yes, please explain:
Do you have a passport?	Yes No
Do you have a pending legal issue?	Yes No
If yes, please explain:

Do you smoke?	Yes No
If yes, how much and how often do you smoke?
Do you drink alcohol?	Yes No
If yes, how much and how often do you drink?
Are you currently using any other substances?	Yes No
If yes, what kind, how much, and how often do you use these substances?

Where did you grow up?
What was your family like?
Who do you live with now?
Are they clean?	Yes No
What is your educational background?
Where do you work?
Have you lost friends or family members to addiction?	Yes No
What is the hardest thing you've ever worked for?
What do you value most in your life?
What were the four happiest months of your life?
What were the four saddest?

List medications you are taking and daily dosages:	Please pay special attention to anti-depressants, anti-anxiety medications, benzodiazepines, and QT prolonging medications (if the bottle says to avoid grapefruit while taking your medication, you probably are dealing with a QT prolonger):
Are you suffering any emotional or mental conditions?	Yes No
Check all that apply:
Bi-Polar Schitzophrenia Depression PTSD Obsessive/Compulsive Eating Disorders Other
If yes to any of the above please expand upon or explain:
List history and treatment for any of these conditions:
What are your spiritual beliefs or practices?
How do you handle emotional experiences?

How would you characterize your overall physical condition?
When was the last time you saw a doctor?
For what reason?
Do you have any physical conditions?	Yes No
Check all that apply:
Diabetes Stroke Hepatitis A, B, or C Headaches Bleeding Abdominal pain Stomach problems History of ulcers Liver problems Slow heart rate History of seizure Jaundice Urinary problems Thyroid problems Heart problems Heart disease Low blood pressure Respiratory problems Asthma Loss of menstruation Painful menstruation Excessive menstruation Cancer Swelling Fainting Joint pain Numbness Varicose veins Diarrhea Back problems HIV positive / AIDS Nausea Shaking Dizzy spells Tuberculosis High blood pressure Shortness of breath Renal disease Muscle spasm Nerve damage Heartburn Constipation Obesity
Please list any surgeries and dates:

How long have you been clean in the past?
Have you been to any rehab or treatment programs?
If yes, please list details and personal opinions of these experiences:
What has worked to stay clean?
What are your goals for recovery?
Do you have a healthy environment to return to?
Either way, what does this environment look like?
What do you like to do when you're not using?
What is your after treatment plan?
Do you believe people can live happy and clean?	Yes No
Are you willing to give yourself a year to recover?	Yes No
Will you seek therapy before and after treatment?	Yes No
Are you willing to experience some discomfort and restlessness while detoxing?	Yes No
Part of the process of opiate detox may include extended periods of sleeplessness. 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 provided and any data gathered during your treatmentfor research purposes. None of your personal information will be associated with this data. Any information that can be added to the growing knowledge base for ibogaine therapy will lead one step closer to the legitimization and legalization of this very important medicine. Thank you!

I agree to allow this information to 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.