Application for Detox Treatment

Application for Ibogaine Detox Therapy

Awakening in the Dream San Miguel de Allende/ Botánicos Desintoxicación y Tratamiente Natural S.C.
Please use this application if you have any current addiction or active substance dependency. Once your application is received and processed, we will develop an individualized treatment plan for your specific situation, and provide preparatory guidance and instructions. For example; 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. Alcohol and stimulant treatments will require abstinence for a period of time prior to taking Ibogaine. These are essential factors to create conditions for a safe and effective treatment for you. If we feel we are not able to provide the treatment that an individual requires, we reserve the right to decline any application. Thank you for your interest and we look forward to talking with you further.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Height*
Patient Weight*
Patient Gender*
Patient E-Mail*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What country are you in?*
Do you have a valid passport?*

yesno
How did you hear about us?
Who do you live with?*
Marital Status*
Emergency Contact*

Name

Relationship to you

Phoneemail

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 NameLast Name
CityState
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

First NameLast Name
CityState
Psychiatric Care Provider Phone Number
Please enter a valid phone number.
Psychiatrist Email
example@example.com
Would you like a referral for an ibogaine-informed therapist?
Reason for seeking Ibogaine Treatment:*
Goals for Ibogaine Therapy*
Please describe any previous experience with psychedelics or entheogenics:*
Mental Health and Psychosocial History
Have you been diagnosed with any of the following (select all that apply):*

DepressionBipolar DisorderAnxietyPersonality DisordersObsessive Compulsive DisorderADD/ADHDEating DisorderSchizophreniaSubstance Use DisorderPTSDEpisodes of PsychosisSuicide AttemptsSuicidal IdeationOther mental/behavioral health issuesExperienced some the above but not officially diagnosed
Briefly describe any of the above and treatment received:*
How would you characterize your current mental health? *
Describe your use of substances in the last 30 days (Substance/s used, method of administration, amounts, frequency? ):*
Describe your history of drug and alcohol use, eating disorders, or other addictive behaviors starting with original onset to present:*
Briefly describe any rehab programs you have experienced:*
How long have you been free of chemical dependency in the past?*
What has worked for you to remain in recovery?*
Do you have family members or housemates with addiction issues?*
Have you lost friends or family to addiction issues?*
Do you believe people can live a happy life free of substances?*
What do you like to do when you are not using substances?*
Are you willing and prepared to experience a period of sleeplessness, restlessness and possibly discomfort while detoxing?*
What are your concerns or fears about the detox process?*
What are your current goals for recovery?*
Are you willing to give yourself a year to focus on recovery and integrate your experience?*
What is your after treatment plan?*
Will you seek therapy before and after this treatment? Are you currently in therapy?*
What is your educational background?*
What is your occupation and where do you work?*
Where did you grow up and what was your family life like?*
How do you handle emotional experiences?*
How would you describe your spiritual health?*
Can you outline your spiritual beliefs and practices?*
What is the thing you have worked hardest for in life?*
What do you value most in life?*
What have been the four happiest moments in your life?*
What were the four saddest moments in your life?*
Patient Medical History
Please list any allergies:*
known drug allergies, medications, food, environmental
How would you describe your current physical condition?*
When was the last time you saw a doctor and for what reason?*
Please list any surgeries, major illnesses or hospitalizations and the year:*
Description and date of any serious injuries or accidents:*
Please list any other health conditions or diagnoses you have or have had:*
Please describe any family history of serious illness or chronic illness:*
Siblings, Parents, Grandparents
Symptom Review

Do you have or have you ever had (Please check all that apply)
HEENT*

Dental Pain or infectionsGlaucomaSinus InfectionsNasal BlockageNone
RESPIRATORY*

AsthmaChronic CoughRecurrent BronchitisEmphysemaShortness of BreathSleep ApneaTuberculosisNone
CARDIAC/CIRCULATORY*

Angina/Chest PainHeart DiseaseArrhythmiaBradycardiaStroke/TIAVaricose VeinsEdema or swellingFaintingHigh blood pressureLow blood pressurePalpitationsNone
ABDOMINAL/DIGESTIVE*

Difficulty SwallowingAbdominal pain/bloatingDistress from fatty foods (nausea, dizziness, headaches, etc)Food AllergiesHypoglycemiaNauseaStomach ProblemsHeartburn/RefluxUlcersGallstonesHepatitis/Liver DiseaseH. PyloriJaundiceColitisConstipationDiarrheaChange in bowel habitsNone
GENITOURINARY*

Bladder infectionsFrequent UrinationKidney Disease/StonesSexually Transmitted DiseaseErectile DysfunctionProstate IssuesNone
GYNECOLOGIC*

Painful MenstruationExcessive MenstruationLoss of MenstruationBreast PainInfertilityUterine/Vaginal InfectionsNot Applicable or None
ENDOCRINE*

Diabetes Type 1Diabetes Type 2Thyroid IssuesReduced LibidoNone
NEUROLOGICAL*

TremorDizziness/VertigoEpilepsy/SeizuresWeaknessNumbnessMemory LossMigraines/HeadachesVision changesNerve damage/NeuropathyConcussionsNone
MUSCULOSKELETAL*

Arthritis/Joint PainSciatica/Low Back PainMuscle Pain/SpasmTendonitis/BursitisFracturesNone
INFECTIOUS*

CandidaChicken Pox/ShinglesHerpes I/IIHIVMeningitisMononucleosisNone
OTHER*

Alcohol or Substance abuseAnemiaBruising/Bleeding TendencyCancer/LeukemiaWeight problems/ChangesFatigueChemical sensitivitiesKnown toxic exposuresNone
Do you rely on any adaptive equipment or medical devices? Please describe.*
ex.; CPAP, Oxygen, Walker, Cane, etc
Current Prescription Medications*
Current Supplements*
Health Habits
Exercise*

Never1-2 days/week3-4 days/week5+ days/week
What type/s of exercise do you do?
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke or use nicotine?*

No0-1 pack/day1-2 packs/day2+ packs/dayNicotine other than cigarettes
Please describe your average daily diet:*
Any dietary restrictions or requirements?*
Include other comments regarding your Medical History
Signature

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Application for Ibogaine Detox Therapy

Mental Health and Psychosocial History

Patient Medical History

Symptom Review

Health Habits