Casita Iboga Substance Detox Session Application
Reason for Seeking Treatment
State/Provlnce/Territory and Country of Current Residence
Preferred Method of Contact
Emergency Contact Name and Telephone
Are you currently under a physician's care? Please briefly describe.
List all prescribed drugs and supplements you are taking, including dosage and frequency.
List major surgeries and hospitalizations, including dates.
Describe any dietary restrictions.
Please check all that apply:
High Blood Pressure
Low Blood Pressure
History of Ulcers
Hepatitis A, B, or C
History of Seizures
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.
What are your spiritual beliefs and practices, if any?
Have you independently studied Iboga?
If so, did anything stand out to you?
Where did you grow up? How would you describe your childhood?
What is your current home life like? If any, are the people you live with supportive?
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 do you enjoy doing when you are clean/sober?
How long have you been clean in the past? How did you do it?
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.
I am willing to experience periods of insomnia post session.
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:
Use this field to attach any test results (liver panel, EKG, etc.)