Get to Know you by filling out the questionairre

This intake questionnaire serves as an opportunity for us to get to know you. We will forward this information to our doctor and therapists so that they may better assist you in your healing journey.
***PLEASE NOTE - THIS FORM MUST BE FILLED OUT AND SUBMITTED IN ONE SITTING AT THE COMPUTER. WE CAN ALSO EMAIL YOU THE SAME FORM IF YOU PREFER.
There are no right or wrong answers and we understand that your life likely has many aspects to it that you feel are not expressed positively. We ask that you make every attempt to answer truthfully and "look within" wherever possible. Ultimately, this will be about your healing and restoration.

Name ( First & Last ) *

* Indicates required field

Email *

Phone Number *

Address *

Emergency Contact ( name & phone ) *

Age, Height, Weight *

Date you are requesting for a treatment appointment if you are not already scheduled? *

How did you hear about us? *

PHYSICAL HEALTH

What is your current diet like? Do you have any specific dietary requirements or food allergies? What are your favorite foods? *

Please list any food that you dislike or that disagrees with you? *

Do you have a physical fitness routine? *

Do you have a physical limitation that we need to be aware of? *

Do you have ongoing issues with pain? If so, what is the pain issue and what do you do for pain management? *

DRUG/ALCOHOL USE

What is your relationship with alcohol? How often do you use it? At what age did you start drinking? *

Do you smoke? If so, how often and how much? *

If you do smoke cigarettes, do you view this as a problem and have a desire to quit? *

What drugs have you used in the past? What is your drug of choice? Why? *

What is the quantity and frequency of your drug use and over how many months and years? Feel free to be completely truthful. This is a detoxification setting and not a place of judgment. *

Have you ever experimented with Psychedelic Drugs or Psychedelic Plant Medicines *

If so, which plants or drugs? How many times? What was your experience like? *

Have you tried to detox before? What methods did you use? *

MEDICAL QUESTIONS

List of Any Medications you are currently taking (or have taken in the last 30 days) and the daily dosage: *

Please list any non-prescribed medications (street drugs) used in the last 30 days: *

Are you taking any antidepressant drugs (SSRI)? If so, please explain and include dose: *

Any medication prescribed to you that you are not currently taking? *

Are you taking any supplements, vitamins, herbs, or performance enhancing drugs? *

Are you allergic to any food or medication? If yes, explain. *

Have you had any major surgeries? If yes, what was the surgery and approximate date? *

Heart Health: Do you have a history of heart disease, slow heart rate, myocardial infarction, or any other heart problems? If yes, explain: *

Any history of high or low blood pressure - (hypertension or hypotension)? If yes, explain: *

Any history of seizures? If yes, explain: *

Any history of vascular disease or aneurysm? If yes, explain: *

Any history of blood clotting & embolism? If yes, explain: *

Do you have diabetes? Are you dependent on insulin? *

Any fainting spells or dizziness? If yes, explain: *

Do you have any history of ulcerative colitis, Crohn's Disease, peptic ulcers, diverticulosis, diverticulitis, or IBS? If yes, explain: *

Liver: Do you have any type of hepatitis (A,B,C), any abnormal liver function tests, jaundice, or any other liver problems? If yes, explain: *

Any history of brain damage including traumatic or closed head injuries? If yes, explain: *

Are you asthmatic? If yes, do you use an inhaler? Do you have any other respiratory problems/lung issues/shortness of breath/TB/COPD/emphysema? Explain: *

Any thyroid issues? Are you taking thyroid medication? *

Menstrual Issues: Any pain, excessive bleeding, or loss of periods? *

Any swelling or joint pain? Explain: *

Any history of muscle spasms or back problems? Explain: *

Are you HIV positive or have AIDS? If yes, explain *

Any history of cancer? If yes, explain: *

Do you have any history of heartburn or stomach problems? If yes, explain: *

Any history of renal disease or other kidney issues? If yes, explain: *

Do you have any nerve damage or numbness? Explain: *

Do you have any urinary problems, diarrhea, or constipation? If yes, explain: *

Do you have sleep apnea? Do you use any type of sleeping aids? Explain: *

Have you ever had a stroke? If yes, provide details of the incident: *

MENTAL HEALTH

Have you experienced a major life trauma? If so, please explain *

Have you experienced any childhood trauma? Example: sexual abuse, physical abuse, emotional abuse, or neglect. If yes, please explain: *

If you have experienced childhood trauma did you disclose this to anyone? If so, what was their response? Please give a brief description: *

Was there an event that preceded your very first drug use? Please think carefully and describe anything that comes to mind. *

Have you ever had thoughts of suicide? If yes, explain: *

Have you struggled with depression in your life? Explain: *

Have you ever experienced a psychotic break? If yes, explain: *

Do you experience extreme anger or frustration? If yes, when did your last outburst occur? Please explain: *

Have you ever been in a psychiatric hospital? If yes, please explain the circumstances and do you think that you have recovered from the experience? *

How would people that know you well characterize your mental state? *

What is YOUR description of your current mental state? *

Have you ever been diagnosed with a mental imbalance or disorder? If yes, please explain the medical diagnosis and treatment used? How do you feel about this? *

What is your general emotional state? *

Tune into your heart and spirit, what do you feel? *

RELATIONSHIPS

Are you in a relationship? Do you feel that your partner can support your recovery? Does your partner use as well? *

Who in your life can you confide in and trust? *

Are your friends and close peers using drugs or addicted to drugs? *

How stable are your existing close relationships? *

How do you feel that your existing relationships could improve? *

SPIRITUALITY

Do you have a practice of prayer or meditation? *

Do you feel a connection with nature? *

Have you ever experienced a spiritual awakening? *

Do you remember your dreams? If so, what do you dream about? *

How is your intuition? *

Is there anything else you would like to share about your spirituality? *

BEHAVIORAL HEALTH

What do you currently do for work? Are you happy with it? *

Do you feel like you know your purpose in life? If so, briefly describe it? *

What is your biggest concern about undergoing Ibogaine treatment? *

WHY?

Why do you want to get clean? *

Are you willing to make the necessary changes to maintain your sobriety? This could include changing friendships, personal relationships, work, residence, & more. *

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GET TO KNOW YOU