Veteran Ibogaine Financial Aid Application

Financial Aid Application

Full Name

Age

Address

Email Address

Street Address Line 2

City

Country

Phone Number

Format: (000) 000-0000.

Section 2: Purpose of Applying

Primary reason for attending this retreat

What are you hoping to heal change or overcome

What therapies or programs have you tried before

Why is this retreat the right fit for you

Commitment level to full program and aftercare?

Section 3: Financial Situation

Employment status

Average monthly income USD

Estimated monthly housing cost USD

Other monthly obligations or debts describe amounts

Do you have savings or family support available

How much can you personally contribute USD

Open to payment plan? (Yes/No/Maybe)

Request type (Full scholarship / Partial / Payment plan only):

Scholarship amount requested USD

Section 4: Health & Safety Screening

Any current or past medical conditions? (Yes/No)

If yes please list conditions and dates

Currently taking prescription medications? (Yes/No)

If yes list medication names doses and prescriber

Substance use in last 30 days (alcohol or other)? (Yes/No) If yes specify substances frequency and last use date

Ever diagnosed with a mental health disorder? (Yes/No) What symptoms are you currently experiencing?

Section 5: Motivation & Responsibility

What changes are you willing to make beforeafter the retreat

How do you plan to integrate what you learn

What does accountability mean to you in this process

If approved, are you willing to give a testimonial? (Yes/No/Anonymous)

Are you willing to volunteer, refer, or otherwise give back? (Yes/No/Maybe)

Section 6: Documentation & Verification

Upload proof of income (w2, paystub, or 1099)

Reference name

Reference email or phone

Format: (000) 000-0000.

If referred by whom

Section 7: Logistics & Availability

Do you have a valid passport? (Yes/No)

Available for retreat dates within next 90 days? (Yes/No/Depends)

Section 8: Eligibility

What branch of the military did you serve in?

Upload military ID

Section 9: Consents & Agreements

I am willing to get an EKG and blood test in order to qualify for ibogaine treatment (YES/NO)

I understand financial aid is limited and contingent on full participation (Yes/No)