Ibogaine Therapy Application
Ibogaine is an extremely powerful and profound medicine. While it has the ability to break deep addictive cycles, it also can be very dangerous, and even fatal for those who undergo the treatment without giving a full and truthful medical background.

Complete openness and honesty in answering the following questions sets the tone for the entire therapy relationship. Even if you are a good candidate for Ibogaine, not providing full and truthful information at this stage breaks our trust and means you will no longer be considered for treatment.

We’ve heard everything before and pass absolutely no judgement, so please answer fully and honestly.

Email address *
Next
Never submit passwords through Google Forms.
This form was created inside of The Root of Hope. Report Abuse - Terms of Service