Application for Ibogaine Detox Therapy
Awakening in the Dream San Miguel/ Botánicos Desintoxicación y Tratamiente Natural S.C.
Prior to proceeding with your Ibogaine treatment, it is important to fill out the following medical and mental health assessment. Please answer all questions as accurately as possible, paying special attention to medical history and substance use profiles. Incomplete or false information can lead to unintended consequences that may greatly affect your treatment and could even lead to serious harm, including death. Please understand that most, if not all,of the Ibogaine related complications or deaths have occurred because of the use of opiates or other drugs taken during or immediately following treatment. Pre-existing heart problems, inaccurate reporting of dosages, or not disclosing other medications being consumed including psychiatric medications, all create an elevated risk when combing with Ibogaine. We ask you to return the application form as soon as possible so that we have sufficient time to evaluate you for any potential risks or contraindications and prepare you for a safe and productive treatment experience. If you are taking antidepressants, anti-convulsives, or other psychiatric medications it will be important to taper off them in the weeks-days preceding your treatment. This is important because Ibogaine works in the same pathways as many mental health medications. A greater length of time off of these medications will result in an improved treatment outcome. You can review the process of getting off of these medications with your personal prescriber, or we can provide detailed instructions on how to do this including supplement routines that you can begin immediately to aid in preparations. If you have any current addiction or substance abuse issues, it may be necessary for you to either change your substance or dosage,or to detox prior to treatment in order to be medically and chemically stable during Ibogaine treatment. We will work closely with you to determine the requirements based on the substance used and your treatment plan. Opiates may need to be transitioned to a stabilizing form- for example switching long acting or synthetic (Suboxone, Methadone) to short acting, sometimes this process can take a month or so. This is important to create conditions for a safe and effective treatment for you. Alcohol and stimulant treatments will require abstinence for a period of time prior to taking Ibogaine therapy. This will all be clarified by our providers for your specific situation once your application is received and processed. Contraindications for Ibogaine treatment include advanced liver disease with enzymes four times above normal levels, heart disease, pneumonia, morbid obesity, untreated diabetes, uncontrolled hypertension, hyper-coagulable states (increased risk for blood clots) and current active infections. If you have a history of any heart, kidney or liver conditions, we will need to accurately assess your situation in order help to prepare you for a safe treatment. If you have any chronic intestinal or digestive issues, we can also help you prepare for any exacerbation of these issues during or following your experience. Prior to your experience, it is important that you receive a medical checkup, including a resting EKG and the following blood tests: Basic Metabolic Panel, liver function panel, CBC with differential[QS35, BHc in Mexico]. For those 60 years of age and older, we require an additional stress test to make sure that your body will be able to handle the potential intensity of this treatment. These tests need to be completed with your personal physician prior to acceptance and scheduling of your treatment. Thank you for your interest and we look forward to talking with you further.
Patient Name
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First Name
Last Name
Patient Birth Date
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Year
Patient Height
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inches
Patient Weight
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pounds
Patient Gender
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Please Select
Male
Female
Other
Patient E-Mail
*
example@example.com
Phone Number
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-
Country Code
-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What country are you in?
Do you have a passport?
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yes
no
How did you hear about us?
Who do you live with?
*
Please Select
Alone
Roommate/s
Spouse
Relatives
Homeless
Marital Status
*
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Single
Partnered
Married
Divorced/Separated
Widowed
Emergency Contact
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Name
Relationship to you
Phone
email
Address/City & State/ Zip Code
Name of Medical Care Provider/Doctor (We do not plan to contact your health care providers without your consent
*
First Name
Last Name
City
State
Doctor's Phone Number
*
Please enter a valid phone number.
Doctor's Email
example@example.com
Name of Psychiatric Care Provider/Therapist (We do not plan to contact your health care providers without your consent
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First Name
Last Name
City
State
Psychiatric Care Provider Phone Number
*
Please enter a valid phone number.
Psychiatrist Email
example@example.com
Do you need a referral for an ibogaine-informed therapist?
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Reason for seeking Ibogaine Treatment:
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Goals for Ibogaine Therapy
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Please describe any previous experience with psychedelics or entheogenics:
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Mental Health and Psychosocial History
Have you been diagnosed with any of the following:
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Depression
Bipolar Disorder
Anxiety
Personality Disorders
Obsessive Compulsive Disorder
ADD/ADHD
Eating Disorder
Schizophrenia
Substance Use Disorder
PTSD
Episodes of Psychosis
Suicide Attempts
Suicidal Ideation
Other Mental Health/Behavioral issues
Never been diagnosed
Briefly describe any of the above and treatment received:
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How would you characterize your current mental health?
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Describe your use of substances in the last 30 days (Substance/s used, method of administration, amounts, frequency? ):
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Describe your history of drug and alcohol use, eating disorders, or other addictive behaviors starting with original onset to present:
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Briefly describe any rehab programs you have experienced:
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How long have you been free of chemical dependency in the past?
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What has worked for you to remain in recovery?
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Do you have family members or housemates with addiction issues?
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Have you lost friends or family to addiction issues?
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Do you believe people can live a happy life free of substances?
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What do you like to do when you are not using substances?
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Are you willing and prepared to experience a period of sleeplessness, restlessness and possibly discomfort while detoxing?
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What are your concerns or fears about the detox process?
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What are your current goals for recovery?
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Are you willing to give yourself a year to focus on recovery and integrate your experience?
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What is your after treatment plan?
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Will you seek therapy before and after this treatment? Are you currently in therapy?
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What is your educational background?
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What is your occupation and where do you work?
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Where did you grow up and what was your family life like?
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How do you handle emotional experiences?
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How would you describe your spiritual health?
Can you outline your spiritual beliefs and practices?
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What is the thing you have worked hardest for in life?
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What do you value most in life?
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What have been the four happiest moments in your life?
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What were the four saddest moments in your life?
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Patient Medical History
Please list any allergies:
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known drug allergies, medications, food, environmental
How would you describe your current physical condition?
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When was the last time you saw a doctor and for what reason?
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Please list any surgeries, major illnesses or hospitalizations and the year:
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Description and date of any serious injuries or accidents:
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Please list any other health conditions or diagnoses you have or have had:
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Please describe any family history of serious illness or chronic illness:
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Siblings, Parents, Grandparents
Symptom Review
Do you have or have you ever had (Please check all that apply)
HEENT
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Dental Pain or infections
Glaucoma
Sinus Infections
Nasal Blockage
None
RESPIRATORY
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Asthma
Chronic Cough
Recurrent Bronchitis
Emphysema
Shortness of Breath
Sleep Apnea
Tuberculosis
None
CARDIAC/CIRCULATORY
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Angina/Chest Pain
Heart Disease
Arrhythmia
Bradycardia
Stroke/TIA
Varicose Veins
Edema or swelling
Fainting
High blood pressure
Low blood pressure
Palpitations
None
ABDOMINAL/DIGESTIVE
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Difficulty Swallowing
Abdominal pain/bloating
Distress from fatty foods (nausea, dizziness, headaches, etc)
Food Allergies
Hypoglycemia
Nausea
Stomach Problems
Heartburn/Reflux
Ulcers
Gallstones
Hepatitis/Liver Disease
H. Pylori
Jaundice
Colitis
Constipation
Diarrhea
Change in bowel habits
None
GENITOURINARY
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Bladder infections
Frequent Urination
Kidney Disease/Stones
Sexually Transmitted Disease
Erectile Dysfunction
Prostate Issues
None
GYNECOLOGIC
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Painful Menstruation
Excessive Menstruation
Loss of Menstruation
Breast Pain
Infertility
Uterine/Vaginal Infections
Not Applicable or None
ENDOCRINE
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Diabetes Type 1
Diabetes Type 2
Thyroid Issues
Reduced Libido
None
NEUROLOGICAL
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Tremor
Dizziness/Vertigo
Epilepsy/Seizures
Weakness
Numbness
Memory Loss
Migraines/Headaches
Vision changes
Nerve damage/Neuropathy
Concussions
None
MUSCULOSKELETAL
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Arthritis/Joint Pain
Sciatica/Low Back Pain
Muscle Pain/Spasm
Tendonitis/Bursitis
Fractures
None
INFECTIOUS
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Candida
Chicken Pox/Shingles
Herpes I/II
HIV
Meningitis
Mononucleosis
None
OTHER
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Alcohol or Substance abuse
Anemia
Bruising/Bleeding Tendency
Cancer/Leukemia
Weight problems/Changes
Fatigue
Chemical sensitivities
Known toxic exposures
None
Do you rely on any adaptive equipment or medical devices? Please describe.
*
ex.; CPAP, Oxygen, Walker, Cane, etc
Current Prescription Medications
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Current Supplements
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Health Habits
Exercise
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Never
1-2 days/week
3-4 days/week
5+ days/week
What type/s of exercise do you do?
Alcohol Consumption
*
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
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I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke or use nicotine?
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No
0-1 pack/day
1-2 packs/day
2+ packs/day
Nicotine other than cigarettes
Please describe your average daily diet:
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Any dietary restrictions or requirements?
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Include other comments regarding your Medical History
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