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.

General Information
Name *
Name
Gender
Contact Information
Phone *
Phone
Address
Address
Emergency Contact Information
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
Doctor's Name
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Therapist or Psychiatrist's Name
Therapist or Psychiatrist's Name
Therapist or Psychiatrist's Phone
Therapist or Psychiatrist's Phone
Household Info
i.e. Apartment, Homeowner, Alone, Roommate, etc.
About You
Have you ever used ibogaine?
Do you have any allergies?
If yes, please explain
Do you smoke?
Do you drink alcohol?
Are you currently using any prescription or non-prescription substances?
If you answered No above, please put n/a
If you answered No above, please put n/a
Are you suffering from any emotional or mental conditions?
Check all that apply
History of violence?
History of self-mutilation/self harm?
Do you have any physical conditions or illness?
Please check all that apply to you
Please check all that apply to your family history
(in the last 10 years)
When would you like to come for treatment?
When would you like to come for treatment?
Is there anything else you'd like to mention?
Please include how you found us, or the name of person who referred you
Legal Disclaimer *

Information Usage & 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 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!