subject_line
Casita Iboga Psychospiritual Session Application
Name
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Reason for Seeking Treatment
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State/Provlnce/Territory and Country of Current Residence
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Age
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Height
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Weight
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Gender
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Email
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Telephone
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Skype Username
Preferred Method of Contact
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Email
Telephone
Skype
Emergency Contact Name and Telephone
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Are you currently under a physician's care? Please briefly describe.
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List all prescribed drugs and supplements you are taking, including dosage and frequency.
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0/255 characters
List major surgeries and hospitalizations, including dates.
Describe any dietary restrictions.
Please check all that apply:
COPD
High Blood Pressure
Low Blood Pressure
Headaches
History of Ulcers
Circulatory problems
Constipation
Cancer
Heart Disease
Digestive Problems
Breathing Difficulty
Stomach Problems
Wounds/Abscesses
Dizziness/Fainting
Hepatitis A, B, or C
History of Seizures
Asthma
Diabetes
Diarrhea
Anemia
Back Injury
Please describe any conditions checked above.
What substances not prescribed are you using? Describe quantity and frequency.
Do you use tobacco? If yes, describe form and quantity.
Do you drink alcohol? If yes, what quantities and frequency? What form?
Do you have any experience with plant medicine or psychedelics?
Please describe any current or past emotional or mental conditions and any treatments.
0/255 characters
What are your spiritual beliefs and practices, if any?
0/255 characters
Have you independently studied Iboga?
Yes
No
If so, did anything stand out to you?
Where did you grow up? How would you describe your childhood?
0/255 characters
What is your current home life like? If any, are the people you live with supportive?
0/255 characters
What is your occupation?
Please describe a typical day.
How do you usually handle emotional events and experiences?
What great disappointments have you experienced in your life? What great joys?
What activities do you enjoy?
What are your plans post session? Please be as detailed as possible. Describe your support system (friends, family, therapists, support groups, etc.).
I am willing to experience discomfort during the session, including nausea, restlessness and emotional distress.
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Yes
I am willing to experience periods of insomnia post session.
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Yes
Your personal information will be held in total confidence. If you agree, we would like to use data about your session, excluding all personal details, to be used to further T.Iboga/ibogaine knowledge and research.
I agree to allow this data, with all identifying details removed, to be used to further knowledge about T.Iboga/ibogaine:
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Yes
No
Use this field to attach any test results (liver panel, EKG, etc.)
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