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

1. Medical History:

2. Mental Health History:

3. Previous Treatment Attempts:

4. Understanding of Ibogaine Treatment:

5. Lifestyle and Support System:

6. Goals and Expectations:

7. Additional Information:

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.

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