Iboga West - Substance Addiction

Name

Reason for Seeking Treatment

State/Provence/Territory and Country of Current Residence

Age

Height

Weight

Gender

Email

Telephone

Skype

Preferred Method of Contact

Email Telephone Skype

Emergency Contact Name and Number

Are you currently under a physician's care? Please briefly describe.

List all prescribed drugs and supplements you are taking, including dosage and frequency.

List major surgeries and dates.

Describe any dietary restrictions.

Please check all that apply

COPD High Blood Pressure Low Blood Pressure

Headaches History of ulcers Circulatory problems

Constipation Cancer 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

Please describe any conditions checked.

What substances not prescribed are you using? Describe quantity and frequency.

Do you smoke or chew tobacco? If yes, describe form and quantity.

Do you drink alcohol? If yes, what quantities and frequency? What form?

Do you have any experience with plant medicine or psychedelics?

Please describe any current or past emotional or mental conditions and any treatments.

What are your spiritual beliefs and practices, if any?

Have you independently studied Iboga?

If so, what stood out?

Where did you grow up? How would you describe your childhood?

What is your current home life like? If any, 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 experienced in your life? What great joys?

What do you enjoy doing when you are clean/sober?

How long have you been clean in the past? How did you do it?

What are your plans post treatment? Please be as detailed as possible. Describe your support system (friends, family, therapists, support groups, etc.).

I am willing to experience discomfort while detoxing, including nausea, restlessness and emotional distress.

Yes

I am willing to experience periods of insomnia post-treatment.

Yes

Your personal information will be held in total confidence. If you agree, we would like to use data about your session, excluding all personal details, to be used to further T.Iboga/ibogaine knowledge and research.

I agree to allow this data, with all identifying details removed, to be used to further knowledge about T.Iboga/ibogaine:

Yes No

Please note! Your choice above in no way affects or determines your fitness for a session.

Use this field to attach any test results: