Application FormPlease fill out the application form below:In order to participate or enquire about ibogaine treatment First Name *Surname *GenderMaleFemaleDate of birth *Height *inchesfeetcm'sWeight *lbskg'sMobile * (Please include full international dialling code eg. +1, +44, +351, +33, etc)Afghanistan +93Albania +355Algeria +213American Samoa +684Andorra +376Angola +244Anguilla +1-264Antarctica +672Antigua +1-268Argentina +54Armenia +374Aruba +297Ascension +247Australia +61Australian External Territories +672Austria +43Azerbaijan +994Bahamas +1-242Bahrain +973Bangladesh +880Barbados +1-246Belarus +375Belgium +32Belize +501Benin +229Bermuda +1-441Bhutan +975Bolivia +591Bosnia & Herzegovina +387Botswana +267Brazil +55British Virgin Islands +1-284Brunei Darussalam +673Bulgaria +359Burkina Faso +226Burundi +257Cambodia +855Cameroon +237Canada +1Cape Verde Islands +238Cayman Islands +1-345Central African Republic +236Chad +235Chatham Islands (New Zealand) +64Chile +56China (PRC) +86Christmas Island +61Colombia +57Comoros +269Congo +242Congo(Democratic Republic of) +243Cook Islands +682Costa Rica +506Cote d'Ivoire (Ivory Coast) +225Croatia +385Cuba +53Cyprus +357Czech Republic +420Denmark +45Diego Garcia +246Djibouti +253Dominica +1-767Dominican Republic +1-809East Timor +670Easter Island +56Ecuador +593Egypt +20El Salvador +503Equatorial Guinea +240Eritrea +291Estonia +372Ethiopia +251Falkland Islands +500Faroe Islands +298Fiji Islands +679Finland +358France +33French Antilles +596French Guiana +594French Polynesia +689Gabonese Republic +241Gambia +220Georgia +995Germany +49Ghana +233Gibraltar +350Greece +30Greenland +299Grenada +1-473Guadeloupe +590Guam +1-671Guatemala +502Guinea Bissau +245Guinea +224Guyana +592Haiti +509Honduras +504Hong Kong +852Hungary +36Iceland +354India +91Indonesia +62Iran +98Iraq +964Ireland +353Israel +972Italy +39Jamaica +1-876Japan +81Jordan +962Kazakhstan +7Kenya +254Kiribati +686Korea (North) +850Korea (South) +82Kuwait +965Kyrgyz Republic +996Laos +856Latvia +371Lebanon +961Lesotho +266Liberia +231Libya +218Liechtenstein +423Lithuania +370Luxembourg +352Macao +853Macedonia +389Madagascar +261Malawi +265Malaysia +60Maldives +960Mali Republic +223Malta +356Marshall Islands +692Martinique +596Mauritania +222Mauritius +230Mayotte Island +269Mexico +52Micronesia +691Midway Island +1-808Moldova +373Monaco +377Mongolia +976Montserrat +1-664Morocco +212Mozambique +258Myanmar +95Namibia +264Nauru +674Nepal +977Netherlands +31Netherlands Antilles +599Nevis +1-869New Caledonia +687New Zealand +64Nicaragua +505Niger +227Nigeria +234Niue +683Norfolk Island +672Northern Marine Islands +1-670Norway +47Oman +968Pakistan +92Palau +680Panama +507Papua New Guinea +675Paraguay +595Peru +51Philippines +63Poland +48Portugal +351Puerto Rico +1-787Qatar +974Reunion Island +262Romania +40Russia +7Rwanda +250St. Helena +290St. Kitts/Nevis +1-869St Lucia +1-758St. Pierre & Miquelon +508St. Vincent & Grenadines +1-784San Marino +378Sao Tomo and Principe +239Saudi Arabia +966Senegal +221Serbia & Montenegro +381Seychelles Republic +248Sierra Leone +232Singapore +65Slovak Republic +421Slovenia +386Solomon Islands +677Somalia +252South Africa +27Spain +34Sri Lanka +94Sudan +249Suriname +597Swaziland +268Sweden +46Switzerland +41Syria +963Taiwan +886Tajikistan +992Tanzania +255Thailand +66Togolese Republic +228Tokelau +690Tonga Islands +676Trinidad & Tobago +1-868Tunisia +216Turkey +90Turkmenistan +993Turks & Caicos Islands +1~649Tuvalu +688Uganda +256Ukraine +380United Arab Emirates +971United Kingdom +44USA Area Codes +1US Virgin Islands +1-340Uruguay +598Uzbekistan +998Vanuatu +678Vietnam +84Venezuela +58Yemen +998Zambia +260Zimbabwe +263Email Address *Skype IDAddressStreet address *Address line 2City *County/Province/StateZip/Post Code *Country *Marital StatusPlease describe what you do in your career, work or studyEmergency ContactEmergency Contact - First Name *Emergency Contact - Surname *Emergency Contact - Mobile *Emergency Contact - Email *About the help you needHow did you hear about us? * (were you referred to us by someone, a web search, a form, other, etc)Did anyone refer you? If so, who? *I am seeking treatment for *Substance AddictionMental DisorderPsycho-SpiritualIn case of substance addiction treatment - What substance(s) are you seeking detoxification from?In case of substance addiction treatment - Have you ever been abstinent from the substance(s) you are seeking to detoxify from?If you have been abstinent, what did you find helpful in maintaining abstinence?Please describe your usual withdrawal symptoms (if any)In case of substance addiction treatment - Please provide a detailed chronological history of your substance use. (What, How Long, Quantity. For example: 2003 - 2007 - 80mg of methadone per day)In case of substance addiction treatment - Please list other detox or treatment programmes you have participated in, and tell us why they did or didn't work for youHave you ever taken iboga or ibogaine before? If yes, please provide more informationMedical informationPlease provide a list of all medications you are prescribed, and are currently taking (What, How Long, Quantity)Please provide a list of all medications you are prescribed, but are NOT currently takingPlease list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month (What, How Long, Quantity)Please list any major surgeries you’ve had in the past, including the date and reason for the procedureDo you suffer from any of these medical conditions?Abdominal PainAbscessArrhythmiaAneurysmAsthmaBack problemsBradycardiaBronchitisCancerCerebellar DysfunctionChronic FatigueCluster headachesCrohn's DiseaseDiabetesDiarrheaDizzy SpellsEmbolismEpilepsyEye painHeart DiseaseHepatitis AHepatitis BHepatitis CHigh Blood PressureHIV Positive/AIDSHypoglycemiaInsomniaJaundiceJoint PainKidney StonesLiver ProblemsLow Blood PressureMuscle SpasmsMyocardial InfarctionNerve damageObesityPalsyPeptic UlcerPericarditisRenal DiseaseSeizuresSexually Transmitted DiseaseShortness of breathStaph infectionStrokeTachycardiaThyroid ProblemsTrauma to the bodyTremorsTuberculosisUlcerative ColitisUlcersUrinary ProblemVaricose VeinsVascular DiseaseVenous ThrombosisOtherIf you answered yes to any of the preceding conditions, please provide details here: Do you have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain. *YesNo Does your family have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain. *YesNo Do you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If yes, please explain. *YesNo Are you taking any steroids or hormones such as Human Growth Hormone? *YesNoHave you ever had a CYP2D6 metabolism test? if so, what was the resultDo you drink alcohol? if yes, how much and how often? *YesNo If you are (or were) an Alcoholic, do you, or have you suffered from DT ( Delirium Tremens)? If yes, please explain. YesNo If you've ever been a smoker, how many cigarettes per day and for how longPlease list all foods and/or medications you are allergic toPlease let us know if you have a restricted dietPsychological / Psychiatric ConditionsIf you are you suffering any emotional or mental conditions, please explainIf you have you ever been admitted to a psychiatric hospital or been diagnosed with any psychiatric conditions, please explainIf you have ever tried to commit suicide, please explainDo you currently suffer from any of the following conditions?Bi-Polar DisorderDepressionSevere DepressionObsessive/Compulsive/Eating DisordersPTSDSchizophreniaN/ALifestyle / BeliefsPlease describe your life goals and the things that are motivating you to recoverPlease describe your social support network (family, friends, co-workers)Please describe your living environment. Do you consider it to be healthy or unhealthy?Do you have any spiritual practices or beliefs?What do you hope to achieve from your ibogaine treatment? (your intention or reason for treatment...) *AftercareWould you like to find out more about how our partners can help support you after your stay with us? YesNoFinal ThoughtsWhat thoughts have you had with regard to improving your life when you leave Tabula Rasa Retreat?Is there anything else you would like to say?InvestmentDo you have the available financial resources, time and commitment for enrollment into our standard ibogaine treatment programme with supporting therapies (€6,621.60 Incl. VAT single occupancy for 5 nights)?YesNoDo you have the available financial resources, time and commitment for enrollment into our extended stay ibogaine treatment programme (€13,243.20 Incl. VAT single occupancy for 12 nights)? – NB. 2 nights FREEYesNoIf iboga / Ibogaine is NOT for you, and you wish to explore other ancestral plant medicines, you can choose to join our exclusive Faith Retreats™ events. NB. some people are unable to be treated with ibogaine due to not meeting our strict inclusion criteria. (Mon am - Sat am, 5 nights programme) €6,621.60 (incl. VAT)YesNo Where would you like to experience ibogaine?*Iboga Root Sanctuary in PortugalIboga Root Sanctuary in Baja, MexicoEither location is goodInterested in learning how ibogaine can help alleviate Parkinson’s symptoms? Let us know if you or someone you know would like more information.YesNoIbogaine treatment is more effective with comprehensive pre-care. Would you like a FREE consultation with one of our trusted therapists?YesNoIbogaine treatment success is enhanced with effective aftercare. Our trusted partners in Thailand provide excellent support at competitive prices. Would you like more information?YesNoI hereby certify that the above information is true and correct to the best of my knowledgePlease uncheck the box if you would not like to receive news and updates from usName *Gender *MaleFemaleHeight (Inches, Feet and cm’s ) *Weight ( lbs,kgs ) *Date Of Birth *Select *Select Your Country CodeAfghanistan +93Albania +355Algeria +213American Samoa +684Andorra +376Angola +244Anguilla +1-264Antarctica +672Antigua +1-268Argentina +54Armenia +374Aruba +297Ascension +247Australia +61Australian External Territories +672Austria +43Azerbaijan +994Bahamas +1-242Bahrain +973Bangladesh +880Barbados +1-246Belarus +375Belgium +32Belize +501Benin +229Bermuda +1-441Bhutan +975Bolivia +591Bosnia & Herzegovina +387Botswana +267Brazil +55British Virgin Islands +1-284Brunei Darussalam +673Bulgaria +359Burkina Faso +226Burundi +257Cambodia +855Cameroon +237Canada +1Cape Verde Islands +238Cayman Islands +1-345Central African Republic +236Chad +235Chatham Islands (New Zealand) +64Chile +56China (PRC) +86Christmas Island +61Colombia +57Comoros +269Congo +242Congo(Democratic Republic of) +243Cook Islands +682Costa Rica +506Cote d'Ivoire (Ivory Coast) +225Croatia +385Cuba +53Cyprus +357Czech Republic +420Denmark +45Diego Garcia +246Djibouti +253Dominica +1-767Dominican Republic +1-809East Timor +670Easter Island +56Ecuador +593Egypt +20El Salvador +503Equatorial Guinea +240Eritrea +291Estonia +372Ethiopia +251Falkland Islands +500Faroe Islands +298Fiji Islands +679Finland +358France +33French Antilles +596French Guiana +594French Polynesia +689Gabonese Republic +241Gambia +220Georgia +995Germany +49Ghana +233Gibraltar +350Greece +30Greenland +299Grenada +1-473Guadeloupe +590Guam +1-671Guatemala +502Guinea Bissau +245Guinea +224Guyana +592Haiti +509Honduras +504Hong Kong +852Hungary +36Iceland +354India +91Indonesia +62Iran +98Iraq +964Ireland +353Israel +972Italy +39Jamaica +1-876Japan +81Jordan +962Kazakhstan +7Kenya +254Kiribati +686Korea (North) +850Korea (South) +82Kuwait +965Kyrgyz Republic +996Laos +856Latvia +371Lebanon +961Lesotho +266Liberia +231Libya +218Liechtenstein +423Lithuania +370Luxembourg +352Macao +853Macedonia +389Madagascar +261Malawi +265Malaysia +60Maldives +960Mali Republic +223Malta +356Marshall Islands +692Martinique +596Mauritania +222Mauritius +230Mayotte Island +269Mexico +52Micronesia +691Midway Island +1-808Moldova +373Monaco +377Mongolia +976Montserrat +1-664Morocco +212Mozambique +258Myanmar +95Namibia +264Nauru +674Nepal +977Netherlands +31Netherlands Antilles +599Nevis +1-869New Caledonia +687New Zealand +64Nicaragua +505Niger +227Nigeria +234Niue +683Norfolk Island +672Northern Marine Islands +1-670Norway +47Oman +968Pakistan +92Palau +680Panama +507Papua New Guinea +675Paraguay +595Peru +51Philippines +63Poland +48Portugal +351Puerto Rico +1-787Qatar +974Reunion Island +262Romania +40Russia +7Rwanda +250St. Helena +290St. Kitts/Nevis +1-869St Lucia +1-758St. Pierre & Miquelon +508St. Vincent & Grenadines +1-784San Marino +378Sao Tomo and Principe +239Saudi Arabia +966Senegal +221Serbia & Montenegro +381Seychelles Republic +248Sierra Leone +232Singapore +65Slovak Republic +421Slovenia +386Solomon Islands +677Somalia +252South Africa +27Spain +34Sri Lanka +94Sudan +249Suriname +597Swaziland +268Sweden +46Switzerland +41Syria +963Taiwan +886Tajikistan +992Tanzania +255Thailand +66Togolese Republic +228Tokelau +690Tonga Islands +676Trinidad & Tobago +1-868Tunisia +216Turkey +90Turkmenistan +993Turks & Caicos Islands +1~649Tuvalu +688Uganda +256Ukraine +380United Arab Emirates +971United Kingdom +44USA Area Codes +1US Virgin Islands +1-340Uruguay +598Uzbekistan +998Vanuatu +678Vietnam +84Venezuela +58Yemen +998Zambia +260Zimbabwe +263Telephone No (Please include full international dialling code. +1, +44, +351, +33) *Email Address *Skype IDAddressStreet Address *Street AddressCountry *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweZIP / Postal Code *City *Please describe what you do in your career, work or studyMarital StatusEmergency ContactEmergency Contact - First Name *Emergency Contact - Surname *Emergency Contact - Email *Emergency Contact - Mobile *About the help you needHow did you hear about us? * (were you referred to us by someone, a web search, a form, other, etc) *Did anyone refer you? If so, who? * *I am seeking treatment for *Please select an optionSubstance AddictionMental DisorderPsycho-SpiritualIn case of substance addiction treatment - What substance(s) are you seeking detoxification from?In case of substance addiction treatment - Have you ever been abstinent from the substance(s) you are seeking to detoxify from?If you have been abstinent, what did you find helpful in maintaining abstinence?Please describe your usual withdrawal symptoms (if any)In case of substance addiction treatment - Please provide a detailed chronological history of your substance use. (For example: 2003 - 2007 - 80mg of methadone one a day)In case of substance addiction treatment - Please list other detox or treatment programmes you have participated in, and tell us why they did or didn't work for youHave you ever taken iboga or ibogaine before? If yes, please provide more informationMedical informationPlease provide a list of all medications you are prescribed, and are currently taking (What, How Long, Quantity)Please provide a list of all medications you are prescribed, but are NOT currently takingPlease list all supplements, nutraceuticals or performance enhancers you’ve taken in the last month (What, How Long, Quantity)Please list any major surgeries you’ve had in the past, including the date and reason for the procedureDo you suffer from any of these medical conditions?Abdominal PainAbscessArrhythmiaAneurysmAsthmaBack problemsBronchitisCancerCerebellar DysfunctionChronic FatigueCluster headachesCrohn's DiseaseDiabetesDiarrheaDizzy SpellsEpilepsyEye painHeart DiseaseHepatitis AHepatitis BHepatitis CHigh Blood PressureHIV Positive/AIDSHypoglycemiaInsomniaJaundicejoint PainKidney StonesLiver ProblemsLow Blood PressureMuscle SpasmsMyocardial InfarctionNerve damageObesityPalsyPeptic UlcerPericarditisRenal DiseaseSexually Transmitted DiseaseShortness of breathStaph infectionStrokeTachycardiaThyroid ProblemsTrauma to the bodyTremorsTuberculosisUlcerative ColitisUlcersUrinary ProblemVaricose VeinsVascular DiseaseVenous ThrombosisOtherIf you answered yes to any of the preceding conditions, please provide details here:Do you have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain. *YESNODoes your family have any history of cardiac abnormalities, myocardial infarction, heart disease, heart attack or stroke? If yes, please explain. *YESNODo you or your family have any history of long QT syndrome, sudden death or unexplained blackouts? If yes, please explain. *YESNOAre you taking any steroids or hormones such as Human Growth Hormone? *YESNOHave you ever had a CYP2D6 metabolism test? if so, what was the resultDo you drink alcohol? if yes, how much and how often? *YESNOIf you are (or were) an Alcoholic, do you, or have you suffered from DT ( Delirium Tremens)? If yes, please explain. *YESNOIf you've ever been a smoker, how many cigarettes per day and for how longPlease list all foods and/or medications you are allergic toPlease let us know if you have a restricted dietPsychological / Psychiatric ConditionsIf you are you suffering any emotional or mental conditions, please explainIf you have you ever been admitted to a psychiatric hospital or been diagnosed with any psychiatric conditions, please explainIf you have ever tried to commit suicide, please explainDo you currently suffer from any of the following conditions?N/ABi-Polar DisorderDepressionSevere DepressionObsessive/Compulsive/Eating DisordersPTSDSchizophreniaPlease describe your life goals and the things that are motivating you to recoverPlease describe your social support network (family, friends, co-workers)Please describe your living environment. Do you consider it to be healthy or unhealthy?Do you have any spiritual practices or beliefs?What do you hope to achieve from your ibogaine treatment? (your intention or reason for treatment...) *AftercareWould you like to find out more about how our partners can help support you after your stay with us? *Please select an optionYesNoFinal ThoughtsWhat thoughts have you had with regard to improving your life when you leave Tabula Rasa Retreat?Is there anything else you would like to say?Do you have the available financial resources, time and commitment for enrollment into our standard ibogaine treatment programme with supporting therapies (€6,621.60 Incl. VAT single occupancy for 5 nights)? *Please select an optionYesNoDo you have the available financial resources, time and commitment for enrollment into our extended stay ibogaine treatment programme (€13,243.20 Incl. VAT single occupancy for 12 nights)? – NB. 2 nights FREE *Please select an optionYesNoIf iboga / Ibogaine is NOT for you, and you wish to explore other ancestral plant medicines, you can choose to join our exclusive Faith Retreats™ events. NB. some people are unable to be treated with ibogaine due to not meeting our strict inclusion criteria. (Mon am - Sat am, 5 nights programme) €6,621.60 (incl. VAT) *Please select an optionYesNoI hereby certify that the above information is true and correct to the best of my knowledgePlease uncheck the box if you would not like to receive news and updates from usSend Message