Language
English (US)
English (US)
Español
IbogaQuest
Tepoztlán, Morelos
info@ibogaquest.com
www.ibogaquest.com
USA:
+1 (802) 748 4600
MEX:
+52 (777) 450 1946
Date/Time Request
IbogaQuest
E-mail
*
Confirmation Email
example@example.com
Personal Data
Section 1 of 6
Full Name
*
Name
Last Name
Age
Birthdate
*
/
Día
/
Mes
Año
Country
*
State
*
City
*
What language(s) do you speak fluently?
*
Ej. Español, Inglés, etc...
Phone Number
*
How can we follow up with you regarding the application?
*
Seleccione
WhatsApp
Email
Phone Call
Text Message
Other
Mention the other method of contact
Gender
Male
Female
Other
Residential Situation
*
e.g., Own, rent, homeless, living with family
Do you have a valid passport?
*
Yes
No
Employment Status
*
Employed
Self-employed
Unemployed
Other
Emergency Contact Name and Relationship
*
e.g., Maria, wife
Emergency Contact Phone
*
Please enter a valid telephone number.
Are you responsible for children?
*
Yes
No
Do you have any current or pending legal issues?
*
Yes
No
Explain what the pending legal matter is about.
*
Atrás
Next
Physical and Medical History
Section 2 of 6
Height
*
Specify the unit of measurement
Weight
*
Specify the unit of measurement
Have you had a physical examination within the past 2 years?
*
Yes
No
If you have HIV/AIDS or Hepatitis, please provide the viral load from your most recent analysis.
*
N/A
Provide the viral load
Do you have any dietary restrictions or food allergies?
*
Yes
No
Please specify all dietary restrictions and allergies.
*
Please specify any physical conditions relating to your comfort or mobility
Please list any medical conditions that will require specific needs or assistance
If you do not have any physical conditions, leave the text box blank.
Do you engage in regular physical exercise?
*
Yes
No
Please specify
*
Have you hade any surgeries?
*
Yes
No
Please list all surgeries and their approximate dates.
*
Do you have a history of seizures?
*
Yes
No
Have you ever been diagnosed with any of the following medical conditions?
*
Abdominal Pain
Asthhma
Back problems
Bleeding
Cancer
Constipation
Diabetes
Diarrhea
Dizzy Spells
Fainting
Headaches
Heart disease
Heart problems
Heartburn
High blood pressure
History of seizures
History of ulcers
Jaundice
Joint pain
Liver problems
Low blood pressure
Menstruation problems
Muscle spams
Nausea
Nerve damage
Numbness
Renal disease
Respiratory problems
Shaking
Shortness of breath
Slow heart rate
Stomach problems
stroke
Swelling
Thyroid problems
Tuberculosis
Urinary problems
Varicose veins
Traumatic Brain Injury (TBI)
None
Other
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Medications and Supplements
Section 3 of 6
Do you currently take any prescription medications?
*
Yes
No
Please list all prescription medications.
*
For each medication, please list: Name, Dosage, Time of day taken, and How long you have been taking it.
Do you currently take any over-the-counter medications, vitamins, or supplements?
*
Yes
No
Please list all over-the-counter medications and supplements.
*
For each, please list: Name, Dosage, and Frequency.
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Substance Use History
Section 4 of 6 - At Iboga Quest, we focus on your safety, dignity, and unique personal journey. We ask for your substance use history so we can work together with compassion, based on the idea of harm reduction. We will not judge or disqualify you based on this information. The most important reason is for your physical safety. Ibogaine can have complex and serious interactions with other substances, and we need to manage this carefully. Beyond safety, we understand that people often use substances as a way to cope with pain, trauma, or other difficulties in life. Understanding your use helps us see the role substances have played for you, which lets us meet you where you are right now. This helps us create a personal plan with the right harm reduction strategies for you, because we don't believe in a 'one-size-fits-all' approach. Please know this is a non-judgmental space. We do not use old, coercive, or shaming methods. Your honesty is the first step for us to build a trusting relationship and give you the best and most respectful support.
Do you consume alcohol?
*
Yes
No
Please include your alcohol of choice, amount consumed (daily, weekly, or monthly), and the longest you have gone without a drink in the past 3 months.
*
Do you use nicotine products?
*
Yes (E.g., smoke, vape)
No
What illicit substances (including Ketamine, Kratom or Cannabis) have you used in the past 3 months?
*
If none, write "None".
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Psychological and Therapeutic History
Section 5 of 6
Do you have a therapist or had been in any therapeutic process?
*
Yes
No
Please explain
*
Will your therapist be supportive through your Ibogaine process?
*
Yes
No
Unsure / I haven't discussed it with them
Do you have a history of detox or rehab?
*
Yes
No
Please elaborate regarding your history with detox/rehab.
*
Do you have a history of self-injury?
*
Yes
No
Please explain
*
Please explain any family history of psychosis.
*
If none, please write "None."
Have you ever been hospitalized for a mental condition?
*
Yes
No
Please specify the condition(s) for which you were hospitalized.
*
Have you been diagnosed with any of the following psychological conditions?
*
Major Depressive Disorder
Depression
Anxiety Disorder
Post Traumatic Stress Disorder (PTSD)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Obsessive-Compulsive and Related Disorders (OCD)
Personality Disorders
Panic and Claustrophobia conditions
Eating Disorders
Somatic Symptom Disorder
Sleep-Wake Disorders
Schizophrenia
Internet Compulsion Disorder
Suicidal Thoughts
Suicidal Attempts
None
Other
Do you engage in regular meditation or other mindfulness practices?
*
Yes
No
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Intentions and Logistics
Section 6 de 6
What is your primary purpose for seeking Ibogaine therapy?
Have you used psychoactive or psychedelic substances before?
*
Yes
No
Which substances have you experienced and was the experience generally positive, negative, or neutral?
*
Have you experienced Iboga or Ibogaine before?
*
Yes
No
Please elaborate on your experience.
*
Please summarize the primary emotional issues you are seeking to address
Please summarize the primary medical issues you are seeking to address
Please share any additional information that might further illuminate your situation and objectives
How did you learn about IbogaQuest?
*
Internet Search
Referral (past attendee)
Spotify Podcast
Social Media
Other
When are you hoping to schedule your treatment?
*
Send
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