Ibogaine Treatment Centers -Tabula Rasa Retreat

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Treatment Application Form

In order to participate or enquire about ibogaine treatment / iboga ceremony please fill out the application form below:

Fields marked with an * are required


    First Name *

    Surname *

    GenderMaleFemale

    Date of birth *

    Height *

    Weight *

    Mobile *  (Please include full international dialling code eg. +1, +44, +351, +33, etc)

    Email Address *

    Skype ID

    Address

    Street address *

    Address line 2

    City *

    County/Province/State

    Zip/Post Code *

    Country *

    Marital Status

    Please describe what you do in your career, work or study

    Emergency Contact

    Emergency Contact - First Name *

    Emergency Contact - Surname *

    Emergency Contact - Mobile *

    Emergency Contact - Email *

    About the help you need

    How did you hear about us? *  (were you referred to us by someone, a web search, a form, other, etc)

    Did anyone refer you? If so, who? *

    I am seeking treatment for *

    In case of substance addiction treatment - What substance(s) are you seeking detoxification from?

    In case of substance addiction treatment - Have you ever been abstinent from the substance(s) you are seeking to detoxify from?

    If you have been abstinent, what did you find helpful in maintaining abstinence?

    Please describe your usual withdrawal symptoms (if any)

    In case of substance addiction treatment - Please provide a detailed chronological history of your substance use. (What, How Long, Quantity. For example: 2003 - 2007 - 80mg of methadone per day)

    In case of substance addiction treatment - Please list other detox or treatment programmes you have participated in, and tell us why they did or didn't work for you

    Have you ever taken iboga or ibogaine before? If yes, please provide more information

    Medical information

    Please provide a list of all medications you are prescribed, and are currently taking (What, How Long, Quantity)

    Please provide a list of all medications you are prescribed, but are NOT currently taking

    Please list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month (What, How Long, Quantity)

    Please list any major surgeries you’ve had in the past, including the date and reason for the procedure

    Do you suffer from any of these medical conditions?Abdominal PainAbscessArrhythmiaAneurysmAsthmaBack problemsBradycardiaBronchitisCancerCerebellar DysfunctionChronic FatigueCluster headachesCrohn's DiseaseDiabetesDiarrheaDizzy SpellsEmbolismEpilepsyEye painHeart DiseaseHepatitis AHepatitis BHepatitis CHigh Blood PressureHIV Positive/AIDSHypoglycemiaInsomniaJaundiceJoint PainKidney StonesLiver ProblemsLow Blood PressureMuscle SpasmsMyocardial InfarctionNerve damageObesityPalsyPeptic UlcerPericarditisRenal DiseaseSeizuresSexually Transmitted DiseaseShortness of breathStaph infectionStrokeTachycardiaThyroid ProblemsTrauma to the bodyTremorsTuberculosisUlcerative ColitisUlcersUrinary ProblemVaricose VeinsVascular DiseaseVenous ThrombosisOther

    If you answered yes to any of the preceding conditions, please provide details here:

    Do you have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain.YesNo

    Does your family have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain.YesNo

    Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If yes, please explain.YesNo

    Are you taking any steroids or hormones such as Human Growth Hormone?YesNo

    Have you ever had a CYP2D6 metabolism test? if so, what was the result

    Do you drink alcohol? if yes, how much and how often? YesNo

    If you are (or were) an Alcoholic, do you, or have you suffered from DT ( Delirium Tremens)? If yes, please explain. YesNo

    If you've ever been a smoker, how many cigarettes per day and for how long

    Please list all foods and/or medications you are allergic to

    Please let us know if you have a restricted diet

    Psychological / Psychiatric Conditions

    If you are you suffering any emotional or mental conditions, please explain

    If you have you ever been admitted to a psychiatric hospital or been diagnosed with any psychiatric conditions, please explain

    If you have ever tried to commit suicide, please explain

    Do you currently suffer from any of the following conditions?Bi-Polar DisorderDepressionSevere DepressionObsessive/Compulsive/Eating DisordersPTSDSchizophreniaN/A

    Lifestyle / Beliefs

    Please describe your life goals and the things that are motivating you to recover

    Please describe your social support network (family, friends, co-workers)

    Please describe your living environment. Do you consider it to be healthy or unhealthy?

    Do you have any spiritual practices or beliefs?

    What do you hope to achieve from your ibogaine treatment? (your intention or reason for treatment...) *

    Aftercare

    Would you like to find out more about how our partners can help support you after your stay with us? YesNo

    Final Thoughts

    What thoughts have you had with regard to improving your life when you leave Tabula Rasa Retreat?

    Is there anything else you would like to say?

    Investment

    Do you have the available financial resources, time and commitment for enrollment into our standard ibogaine treatment programme with supporting therapies (€6,621.60 Incl. VAT single occupancy for 5 nights)?YesNo

    Do you have the available financial resources, time and commitment for enrollment into our extended stay ibogaine treatment programme (€13,243.20 Incl. VAT single occupancy for 12 nights)? – NB. 2 nights FREEYesNo

    If iboga / Ibogaine is NOT for you, and you wish to explore other ancestral plant medicines, you can choose to join our exclusive Faith Retreats™ events. NB. some people are unable to be treated with ibogaine due to not meeting our strict inclusion criteria. (Mon am - Sat am, 5 nights programme) €6,621.60 (incl. VAT)YesNo

    Where would you like to experience ibogaine?*

    Interested in learning how ibogaine can help alleviate Parkinson’s symptoms? Let us know if you or someone you know would like more information.YesNo

    Ibogaine treatment is more effective with comprehensive pre-care. Would you like a FREE consultation with one of our trusted therapists?YesNo

    Ibogaine treatment success is enhanced with effective aftercare. Our trusted partners in Thailand provide excellent support at competitive prices. Would you like more information?
    YesNo

    In order to participate or enquire about ibogaine treatment / iboga ceremony please fill out the application form below:

    Fields marked with an * are required

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