Iboga Intake Form:

Please fill out the entire form below. The fields with the small red asterisk are mandatory to be filled out and the form will not be submitted unless all the information has been filled in. Thank you.

** Once you put an intake form, a file is created and somebody will call you to organize the session.







* Indicates required field





Contact











Most Recent Primary Care Information













Personal Intention



Prior Medical History






Current Medications / Substances







General Health





On a scale of 1-10, 10 being maximum wellness, please rate your current level of wellness for the following dropdown boxes:




Please tell us what type and how much of the following things you consume in the course of a month:


















Please Tell Us About Your Life




Capsules (around 26 capsules)Raw Bark with HoneyAny of the above


























Motivation





Life Chart

Wellness is a balance of many factors. On a scale of 1-10, 1 being the lowest, please rate each of the following areas of your life in terms of happiness by marking the correct column. A score of 10 would mean that you are very happy with that aspect of your life. Conversely, a score of 1 would indicate that you are very unhappy with this area of your life.











Maximum size file: 2MB