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Full Name
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2
Email
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example@example.com
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3
Phone Number
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Please enter a valid phone number.
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4
What's your age?
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5
What is your primary challenge right now?
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Addiction
Depression/Anxiety
Psychospiritual
Other
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6
Have you done any research:
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Other ibogaine sites
Sites like Gaia.com or Maps.com
Listened to podcasts
Other
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7
Do you have any mental illness that causes states of mind, such as:
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Bipolar
Schizophrenia
Severe anxiety disorders
Other
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8
Have you been hospitalized due to issues with your mental health? If so, please explain
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9
Drugs to detox from:
Opiates/Heroin
Fentanyl
Cocaine
Alcohol
Crack
Meth
Other
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10
Quantity of drugs consumed:
Under 1 gram daily
1-3 grams daily
Over 3 grams daily
Binge use (example none for 2 weeks and then having a full weekend of substance use)
Other
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11
Quantity of alcohol consumed:
1-5 drinks per day
5-10 drinks per day
Over 10 drinks per day
Binge drinking (for example none for 2 months and then drinking heavily for a week)
Other
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12
Are you taking any supplements?
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13
We offer personalized treatments tailored to various needs. What budget in USD are you comfortable allocating for this?
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$6,000-10,000
$10,000- 15,000
$15,000-20,000
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14
Book your consultation call below.
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