Application Form
Please fill out as much as you are comfortable with at this stage.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Interested in
Bassé Root Retreat (USA)
Root Healing Europe
Spiritual Care
Other
Which Date Are You Interesteted In?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please enter the date of the start of the retreat date you are most interested in if this applies.
Why are you interested in Iboga?
General Health Information
Height & Weight
Have you had a liver panel test done? If yes, when approximately, and what were the results?
Have you had an EKG (electrocardiogram) test done?
Yes
No
EKG (If you have one now, you can upload it here, but it is better to get this form in first if you dont have it handy. We can collect it later)
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Please share any any medical conditions (diagnosed and undiagnosed) you have? Please also add any past conditions that have been resolved (just label them).
Please list any medications or drugs that you currently use? Please include the start date if you can.
Please list any medications or drugs that you used previously? Please share anything more that you can about dates and length of use.
List all supplements you're currently taking including vitamins, herbs, minerals.
Do you now or have you experienced any of the following? Check all that apply
Rows
Current
Past
Dislike body, shape, or size
Overeating
Eating or overeating when emotional
Purging by vomiting
Excessive Excersive
Use of laxatives or diuretics
Stopped eating or deprive yourself of food
Fear of certain foods
Preocupation of foods causing any illness
Ever been diagnosed or treated for an eating disorder
If you answered current or past to any of the above, please elaborate here.
DIET: Please list any food or environmental allergies you have. What is your current diet? Do you have any dietary restrictions or foods you avoid?
Please list any hospital visits or past surgeries you have had.
Do you currently experience addiction to any drugs or have you in the past? If so, please describe what & frequency/dosage
Are you currently using any recreational drugs regularly? If so, please describe: type, dosage, frequency, as well as last date of use.
List your current health concerns in order of importance
Are you addicted to alcohol, or have you been addicted to alcohol in your past? If so, please describe.
Do you now or have you had a problem(s) with any of the following that has negatively impacted your life physically, mentally, socially, or financially? (check all that apply)
Rows
Current
Past
Cannabis
Alcohol
Opiates
Cocaine
Methamphetamine
Benzodiazepines (Xanax, Valium)
Drugs or Prescription Drugs (not listed above)
Porn
Food
Gambling
Technology
Exercise
If you answered current or past to any of the above, please elaborate here.
Have you used any psychedelics/plant medicines? Please describe your experience.
What questions do you have for the discovery call?
How well do you sleep? Do you feel rested when you get up?
Are there any supplements or medications that you take for sleep? Please elaborate with type, amount, frequency of use, and last use.
Personal & Family History
What's your current relationship with your family & siblings?
Martial/relationship status
Do you have children? Do they live with you?
What's your current relationship with friends?
Have you had any past arrests, charges, or suits against you? Are you currently involved in any type of legal dispute or action either initiated by you or against you?
What are the current stressors in your life?
Have you experienced trauma? Please share below and go into as much detail as you are comfortable with.
Do you engage in any form of self harm? Please go into as much detail as you are comfortable with.
Have you ever had any thoughts of hurting yourself or another? When was the last time?
Do you ever have hallucinations? Paranoid thoughts? Hear voices? Memory loss?
Do you experience any fears or phobias that interfere with your day to day living? If so, what?
Do you experience any sexual dysfunction? I.e. lack of ability or interest in sex?
General
How long have you been thinking about doing Iboga?
Is the medicine calling you?
What are your top three intentions with Iboga?
Is there anything else you would like us to know or that you would like to share?
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