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Full-Intake Form

We invite you to fill out the qualifying intake, as there are some contraindications with IBOGA and some may need extra steps before attending a retreat. Once the intake has been submitted, one of us will be in touch shortly to discuss the next steps. Please note: all fields are required if you do not have an answer please type N/A thank you.

 

IBOGAwaken Full Intake Form

Qualifying health assessment /disclosure statement, please take the time to fill out the information below.

Are you seeking to resolve any of the following?

Combat, terrorism, held hostage or imprisoned, natural or man-made disasters, diagnoses for life-threatening illness, torture.

alcohol, sex, drugs-prescription or recreational, gambling, porn, TV, internet, shopping, smoking, food, exercise, relationships/love, cosmetic surgeries

cutting, picking, scratching, pulling out hair, biting (incl nails)