Please answer all questions as accurately as possible, paying special attention to medical and substance use profiles. Incomplete or false information can lead to unintended consequences that may greatly effect your treatment and may lead to serious harm. Keep in mind that most, if not all, of the Ibogaine related complications or deaths have occurred because of heart problems, inaccurate reporting of substance use, and/or use of opiates during or just after treatment. Thank you for your honesty.
- To apply for Addiction Therapy, you can fill out our online form here.
- To apply for Psycho-Spiritual Therapy, you can fill out our online form here.
A printer-friendly PDF version of this form is also available on our document download page, accessible here.