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Treatment Application Form

Name:*
Address:
Phone:*
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E-mail:*
Skype:
What would be the best way to contact you?
Date of Birth:
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Weight (in kg):*
Height (in m):*
Marital Status:
Number of Dependants:
Any health insurance?*
If so, please provide your health insurance information:
Primary Physician Name:
Primary Physician Phone:
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Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
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Emergency Contact E-mail:
Do you drink alcohol?*
Do you smoke tobacco?*
Do you use Cannabis?*
What substance(s) are you seeking detoxification from?
Are any of these substances prescribed to you by a doctor or therapist?
Have you ever been abstinent from the substance(s) you are seeking to detoxify from?
If so, what did you find helpful in maintaining abstinence?
Please describe your usual withdrawal symptoms:
Are you using any other substances?
Please provide a detailed chronological history of your substance use. (For example: 1990 - 1994 injected heroin twice a day):
Do you have a sex or porn addiction?
Do you have a video game addiction?
Do you have an eating disorder?
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 Narcotics Anonymous or Alcoholics Anonymous?
Do you participate in any other counseling or support groups?
Have you ever tried ibogaine therapy before?
Please describe your plans for aftercare. List any aftercare options which appeal to you:
Please list any medical conditions you are suffering from, even if it appears non important:*
Do you or your family have any history of cardiac abnormalities, heart attack or stroke?*
Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts?*
Please list any medications you are presently taking or have taken in the past 6 months. Please the dosage and how often:*
Please list any depo injections or other injections that you have been given recently or regularly:*
Please list all prior surgeries or operations including dates:*
Do you have a chronic pain issue? If so, what's the source and please rate the severity from 1 to 10:*
Are you taking any steroids or hormones such as Human Growth Hormone?*
Please list any vitamins, supplements, herbal, homeopathic or other similar substances you are taking:*
Do you have any allergies to foods, medications, herbs or drugs?*
Have you ever been diagnosed with or do you have any psychiatric conditions?*
if so, are you currently undergoing care that psychiatric condition?
Have you ever had an Echocardiogram, Cardiac Ultrasound, or Holter test?*
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?*
Have you ever had an adverse or allergic reaction to any medications or drugs?*
Have you ever had a CYP2D6 metabolism test? if so, what was the result?
How often do you do physical exercise?
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?
Have you ever taken a psychedelic or entheogen?
If so, have you had any negative experiences or reactions to these?
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?