Iboga Quest Application

The Iboga Quest Application will help us determine your needs, set a protocol, and let you know the time and costs of Ibogaine treatment. We will also address any concerns you have about Ibogaine and the Iboga experience. We look forward to assisting you on your journey, in a safe setting.

This Application is a guideline of relating to a safe and effective Iboga experience. The questions will help refine your needs, protocol, time and costs and offer a sense of Iboga Quest concerns. Please answer the questions as accurately and fully as possible, paying particular attention to medical and substance use profiles. Candor works to your benefit.

First Name *

Last Name *

Date of Birth *

Home Phone *

Cell Phone *

Email Address *

City, State & Country of Residence *

Residential Situation (i.e own, rent, homeless) *

Emergency Contact Name and relationship *

Emergency Contact Phone *

Do you have a Passport? *

YesNo

What languages do you speak? *

Do you have any current or pending Legal Issues? Explain *

Gender *

MaleFemale

Occupation & Status *

Marital Status & Are you responsible for children? *

Height & Weight *

Any known allergies? *

Are there any current physical conditions or needs IbogaQuest needs to be aware of? *

YesNo

What is your primary and any secondary reason for seeking Ibogaine Therapy? *

List any medical condition(s) you hope or expect Iboga will help with: *

Do you engage in regular physical activity? *

YesNo

List dosage, reason and for how long you have been using any Prescription medications. *

List dosage, reason and for how long you have been using any Over-the-counter medications. *

List all illicit substances including quantity and how it is administered. *

If you drink alcohol, what is your alcohol of choice? How often? How much? What is the longest time you have been without a drink in the past year? *

Do you smoke cigarettes and how much? *

Do you have a physician and have you had an examination within the past 2 years? *

Have you ever been diagnosed with any of the following medical conditions? *

If you have had any surgeries, please explain *

Do you have a therapist? Do you feel your therapist will support you through Iboga therapy? *

Tell us of any history of detox/rehab *

Do you have a history of self-injury? *

Have you been diagnosed with any of the following psychological conditions? *

Do you agree with the diagnosis? *

YesNo

Explain if you you ever been hospitalized for a mental condition? *

Do you engage in regular meditation? *

YesNo

List Psychedelics experienced: *

If you have experienced Iboga tell us where, when and why. *

Is there anything else you would like us to know? *

How did you learn of IbogaQuest? *

When were you hoping to schedule your treatment? *

Iboga Quest Mexico

We are here to help you engage with the strong spirit of the Ibogaine and facilitate an experience of depth; cultivating freedom from these patterns of addiction and habituation.

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