To start your assessment process, please complete the application below, either in its entirety or in part, as appropriate.
Please answer the questions as accurately as possible, paying special attention to medical, psychological and substance use profiles. Thank you for your candor.
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 treatment for 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!