First Name *
Surname *
GenderMaleFemale
Date of birth *
Height *inchesfeetcm's
Weight *lbskg's
Mobile * (Please include full international dialling code eg. +1, +44, +351, +33, etc)Afghanistan +93Albania +355Algeria +213American Samoa +684Andorra +376Angola +244Anguilla +1-264Antarctica +672Antigua +1-268Argentina +54Armenia +374Aruba +297Ascension +247Australia +61Australian External Territories +672Austria +43Azerbaijan +994Bahamas +1-242Bahrain +973Bangladesh +880Barbados +1-246Belarus +375Belgium +32Belize +501Benin +229Bermuda +1-441Bhutan +975Bolivia +591Bosnia & Herzegovina +387Botswana +267Brazil +55British Virgin Islands +1-284Brunei Darussalam +673Bulgaria +359Burkina Faso +226Burundi +257Cambodia +855Cameroon +237Canada +1Cape Verde Islands +238Cayman Islands +1-345Central African Republic +236Chad +235Chatham Islands (New Zealand) +64Chile +56China (PRC) +86Christmas Island +61Colombia +57Comoros +269Congo +242Congo(Democratic Republic of) +243Cook Islands +682Costa Rica +506Cote d'Ivoire (Ivory Coast) +225Croatia +385Cuba +53Cyprus +357Czech Republic +420Denmark +45Diego Garcia +246Djibouti +253Dominica +1-767Dominican Republic +1-809East Timor +670Easter Island +56Ecuador +593Egypt +20El Salvador +503Equatorial Guinea +240Eritrea +291Estonia +372Ethiopia +251Falkland Islands +500Faroe Islands +298Fiji Islands +679Finland +358France +33French Antilles +596French Guiana +594French Polynesia +689Gabonese Republic +241Gambia +220Georgia +995Germany +49Ghana +233Gibraltar +350Greece +30Greenland +299Grenada +1-473Guadeloupe +590Guam +1-671Guatemala +502Guinea Bissau +245Guinea +224Guyana +592Haiti +509Honduras +504Hong Kong +852Hungary +36Iceland +354India +91Indonesia +62Iran +98Iraq +964Ireland +353Israel +972Italy +39Jamaica +1-876Japan +81Jordan +962Kazakhstan +7Kenya +254Kiribati +686Korea (North) +850Korea (South) +82Kuwait +965Kyrgyz Republic +996Laos +856Latvia +371Lebanon +961Lesotho +266Liberia +231Libya +218Liechtenstein +423Lithuania +370Luxembourg +352Macao +853Macedonia +389Madagascar +261Malawi +265Malaysia +60Maldives +960Mali Republic +223Malta +356Marshall Islands +692Martinique +596Mauritania +222Mauritius +230Mayotte Island +269Mexico +52Micronesia +691Midway Island +1-808Moldova +373Monaco +377Mongolia +976Montserrat +1-664Morocco +212Mozambique +258Myanmar +95Namibia +264Nauru +674Nepal +977Netherlands +31Netherlands Antilles +599Nevis +1-869New Caledonia +687New Zealand +64Nicaragua +505Niger +227Nigeria +234Niue +683Norfolk Island +672Northern Marine Islands +1-670Norway +47Oman +968Pakistan +92Palau +680Panama +507Papua New Guinea +675Paraguay +595Peru +51Philippines +63Poland +48Portugal +351Puerto Rico +1-787Qatar +974Reunion Island +262Romania +40Russia +7Rwanda +250St. Helena +290St. Kitts/Nevis +1-869St Lucia +1-758St. Pierre & Miquelon +508St. Vincent & Grenadines +1-784San Marino +378Sao Tomo and Principe +239Saudi Arabia +966Senegal +221Serbia & Montenegro +381Seychelles Republic +248Sierra Leone +232Singapore +65Slovak Republic +421Slovenia +386Solomon Islands +677Somalia +252South Africa +27Spain +34Sri Lanka +94Sudan +249Suriname +597Swaziland +268Sweden +46Switzerland +41Syria +963Taiwan +886Tajikistan +992Tanzania +255Thailand +66Togolese Republic +228Tokelau +690Tonga Islands +676Trinidad & Tobago +1-868Tunisia +216Turkey +90Turkmenistan +993Turks & Caicos Islands +1~649Tuvalu +688Uganda +256Ukraine +380United Arab Emirates +971United Kingdom +44USA Area Codes +1US Virgin Islands +1-340Uruguay +598Uzbekistan +998Vanuatu +678Vietnam +84Venezuela +58Yemen +998Zambia +260Zimbabwe +263
Email Address *
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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 *Substance AddictionMental DisorderPsycho-Spiritual
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?*Iboga Tree in PortugalIboga Tree in Baja, MexicoEither location is good
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
I hereby certify that the above information is true and correct to the best of my knowledge
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