Name :

Email Address :

Email Address (confirm) :

Today's Date :

Age :

Height :

Weight :

City :

State :

Country :

Primary Phone :

Secondary Phone :

Emergency Contact :

Emergency Contact Phone :

Reason(s) for Therapy. Check all that apply :

Other Substances :

Do you smoke? How much? :

Do you drink alcohol? How much? :

Allergies :

Dietary Preferences/Restrictions :

Passport :

Substance use history (please give thorough history of substance use, with quanities) :

Rehabilitation history (please recount all rehab attempts and their efficacy) :

Medical Conditions (including recent hospitalizations and surgeries, and listing all medications) :

Emotional Health/Mental Conditions (A mental/emotional history including hospitalizations and perscriptions) :

What is your plan for aftercare (A secure environment to help you integrate your ibogaine experience) :

Spiritual beliefs :

I understand ibogaine therapy may involve long periods of sleepless and/or discomfort :

I discovered ibogalife.com via :

I understand these answers will not be available to any second party, and that they will only be used for the purposes of determining my eligibility for therapy with IbogaLife. I have answered all questions completely and honestly :