Iboga Therapy House

Ibogaine-Assisted Detox Application

Please fill out the form below and we will contact you shortly.

Please note this application may take up to an hour to fill out completely. If you have any questions or need technical help, please contact us.

All information you provide will be kept strictly confidential.

Personal Information:

First Name

Last Name

Address

City

Province or State

Postal Code or Zip

Country

Citizenship

Phone

Cell

Email

Skype

Please tell us how you prefer to be contacted, and the best time of day to reach you:

Date of Birth

Weight

Height

Marital Status

Dependants

Do you have health insurance?

Do you have health insurance? :: For applicants who live outside of Canada only.

If so, please provide your health insurance information

Primary Physician Name

Physician Phone #

Emergency Contact:

Name

Relationship

Address

City

Province or State

Phone

Cell

Email

Drug History

What substance(s) are you seeking detoxification from? Please list amount or dosage, what form(s) you take it in and how often you use:

Are any of these substances prescribed to you by a doctor or therapist? If so please provide details:

Have you ever been abstinent from the substance/s you are seeking to detoxify from? If so, how long did this period of time last ?

If so, what did you find helpful in maintaining abstinence?

Please describe your usual withdrawal symptoms (if any):

Do you drink alcohol?

Do you drink alcohol? :: If yes, please provide details below when asked about other substances that you use

Do you smoke tobacco?

Do you use Cannabis?

Do you use Cannabis? :: Please provide details about your cannabis use below when asked about other substances. Please also provide details about what forms you use it in, such as whether you smoke it, eat it etc...and whether it is for recreational or therapeutic use. Please be specific.

Are you using any other substances? If so, please list amount or dosage, what form you take it in and how often:

Are you using any other substances? If so, please list amount or dosage, what form you take it in and how often: :: Please include all other substances including alcohol or any other legal or illegal substances

Please provide a detailed chronological history of your substance use:

Please provide a detailed chronological history of your substance use: :: Please list dates and details of your use. ie: 1990 - 1994 injected heroin twice a day and smoked crack 3 -5 times on weekends.

Please list other detox or treatment programs you have participated in, and tell us why they did or didn't work for you:

Have you participated in NA or AA?

Have you participated in NA or AA? :: NA - Narcotics Anonymous or AA - Alcoholics Anonymous

Have you ever tried ibogaine therapy before?

If so, please provide an account of your ibogaine therapy and the outcome:

Do you participate in any counseling or other forms of therapy or support groups? If so, please provide details:

Do you have a sex or porn addiction?

Do you have a video game or MMORPG addiction?

Do you have a video game or MMORPG addiction? :: MMORPG - Massive Multiplayer Online Role-Playing Game

Do you have an eating disorder?

Please describe your plans for aftercare. List any aftercare options which appeal to you:

Medical History

If you answered yes to any of the preceeding questions, please provide details here:

Do you or your family have any history of cardiac abnormalities, heart attack or stroke? If so, please provide details.

Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If so, Please provide details.

Please list any medications you are presently taking or have taken in the past 6 months. Please list amount or dosage and how often:

Please list any medications you are presently taking or have taken in the past 6 months. Please list amount or dosage and how often: :: Please include all medications whether they are prescribed to you or not

Are you taking any steroids or hormones such as HGH (Human Growth Hormone)? If so, please list amount or doseage and how often:

Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking. Please list amount or dosage and how often.

Please list any depo injections or other injections that you have been given recently or regularly:

Do you have a chronic pain issue? If so, please describe:

Do you have a chronic pain issue? If so, please describe: :: Please tell us about the source of your pain and what you do to manage it

If you have chronic pain please describe the severity by choosing on a scale from 1 to 10 (1 represents hardly any pain at all, while 10 represents the worst imaginable pain).

Please list all prior surgeries or operations including dates:

Do you have any allergies to foods, medications, herbs or drugs? If so, please describe:

Have you ever been diagnosed with or do you have any psychiatric conditions? If so, please describe:

Have you ever been diagnosed with or do you have any psychiatric conditions? If so, please describe: :: Please list any conditions such as: Borderline Personality Disorder, Bi Polar Disorder, Major Depression, Uncontrollable Anxiety, Obsessive-Compulsive Disorder, Schizophrenia, Panic Disorder, Eating Disorder, etc...

Are you currently undergoing care for a psychiatric condition? Please describe:

Are you currently undergoing care for a psychiatric condition? Please describe: :: If yes, please also list any medications you are taking for this.

Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)?

Have you ever had an Echocardiogram or Cardiac Ultrasound (ECHO test)? :: An ECHO test, which is a different test than a standard Electrocardiogram (ECG/EKG)

Have you ever had a Holter monitor heart test?

Have you ever had a Holter monitor heart test? :: A heart test where you wear a monitor for 24 hours

Metabolism

Would you consider your metabolism of substances/drugs to be normal, high or low?

When taking substances do you find you usually need more or less than most people do for an effect from a regular dose?

Have you ever taken a substance/drug that had little or no effect? If so please describe.

Have you ever had an adverse or allergic reaction to any medications or drugs? If so please describe what it was and the dosage/s taken.

Have you ever had a CYP2D6 metabolism test?

If so, please tell us what your CYP2D6 metabolism phenotype is:

Exercise patterns

Tell us about yourself

Please describe any goals you have, what kinds of things motivate you in your recovery?

Please describe what you do in your career, work or study:

Please describe what your social support network is like (such as family, friends, co-workers):

Do you have any spiritual practices or beliefs?

Please describe your living environment, do you consider it to be healthy or unhealthy?

Please describe your eating habits and your relationship to nutrition:

Do you feel like you could use some counseling in learning more about nutrition?

Do you have any other special dietary needs or requests?

Have you ever taken a psychedelic or entheogen? If so, please describe:

If so, have you had any negative experiences or reactions to these? Please describe:

Almost done!

Please tell us what your intentions and/or expectations are for your ibogaine therapy:

Is there anything else you would like to tell us about yourself?

Please enter the code you see below exactly as it is shown: