Europe 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
-
Country Code
-
Area Code
Phone Number
Which Date Are You Interesteted In?
-
Month
-
Day
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 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)
Browse Files
Drag and drop files here
Choose a file
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Please list 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
None
Dislike body, shape, or size
Overeating
Eating or overeating when emotional
Purging by vomiting
Excessive Exercise
Use of laxatives or diuretics
Stopped eating or deprive yourself of food
Preocupation of foods causing any illness
Ever been diagnosed or treated for an eating disorder
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?
Do you currently experience addiction to any drugs/alcohol 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 what & frequency, as well as last date of use.
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
None
Cannabis
Alcohol
Opiates
Cocaine
Methamphetamine
Benzodiazepines (Xanax, Valium)
Drugs or Prescription Drugs (not listed above)
Porn
Food
Gambling
Technology
Exercise
Do you use any psychedelics/ plant medicines now or in the past? Please describe your experience.
Personal & Family History
Marital/relationship status
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.
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?
General
How long have you been thinking about doing Iboga?
What are your top three intentions with Iboga?
What questions do you have for the discovery call?
Submit
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