APPLY NOW

Please fill out this Assessment Form to Apply for the program and to determine your ability for ibogaine treatment.

Name

Age

1. Medical History:

Do you have any existing medical conditions? If yes, please specify.

Are you currently taking any medications? If yes, please list them.

Have you undergone any surgeries in the past? If yes, please provide details.

Do you have any history of substance abuse? If yes, please elaborate.

2. Mental Health History:

Have you been diagnosed with any mental health disorders? If yes, please specify.

Have you experienced trauma or significant stressors in the past? If yes, please describe.

Are you currently receiving therapy or counseling? If yes, what type?

3. Previous Treatment Attempts:

Have you tried any other treatments or therapies for your condition(s) before? If yes, please describe the outcomes.

What are your expectations from Ibogaine treatment?

4. Understanding of Ibogaine Treatment:

Have you researched Ibogaine treatment and its potential benefits and risks?

Do you understand that Ibogaine treatment involves psychoactive effects and can be physically and emotionally intense?

Are you committed to following pre-treatment and post-treatment guidelines for Ibogaine therapy?

5. Lifestyle and Support System:

Describe your current living situation.

Do you have a strong support system (family, friends, etc.) to help you through the treatment process?

Are you able to take time off work or other responsibilities to undergo Ibogaine treatment and recovery?

6. Goals and Expectations:

What are your primary goals for undergoing Ibogaine treatment?

What outcomes are you hoping to achieve?

7. Additional Information:

Is there any other information you think is important for us to know when considering your eligibility for Ibogaine treatment?

Please note that this assessment form is designed to gather relevant information to determine your suitability for Ibogaine treatment. Your honesty and thoroughness in completing this form will help us provide you with the best possible care.

APPLY NOW

Download our Free Guide