**Please note that we are unable to accept applications for detox or treatment of addiction.

First Name

Address

City & State

Last Name

Phone

What is your time zone?

List availability for phone consultation:

For which session are you applying?

Group Retreat

Private Session

Emergency Name & Contact

Gender/ Pronoun Preference

Height / Weight

Do you have a passport?

Yes

List any allergies

Medical conditions we should be aware of:

Why are you seeking ibogaine?

Physical activities you engage in regularly and how many times per week:

List any prescription medications you are currently taking:

List any prescription medications you have taken in the last year:

List any over the counter medications you are currently taking:

List any over the counter medications you have taken in the last year:

Do you have a history of addiction? If yes, list substances and time of use:

Have you been through detox or rehab? Provide a brief explanation. Include dates

List any other drugs you have taken in the last year for spiritual or recreational purposes

Do you smoke cigarettes and if so how much?

Have you ever been diagnosed with any medical conditions? If yes, please list

When is the last time you had a check-up with a physician?

Do you have any previous experience with iboga? If yes, please explain where and when:

Have you ever been diagnosed with a psychological condition? If yes, please explain:

Do you drink alcohol?

Yes

If yes, how many days a week do you drink?

One the days that you drink, how many drink do you normally have?

Have you ever been hospitalized for a medical or psychological condition?

Is there anything else we should know?

How did you hear about us?

Retreat Dates:

October 3-7

Please list alternate dates in order of preference (if applicable):

I understand that Iboga Revolution does not offer addiction interruption treatment or any type of detox services.

I accept terms & conditions