Contact

Patient's Full Name: *

Phone: *

Date of Birth: *

Weight & Height:

Email: *

Have You Tried Ibogaine Treatment?

Emergency Contact Name:

Relationship:

Emergency Phone:

Emergency Email:

Preferred Arrival Date:

Medical Evaluation

Purpose for seeking Ibogaine treatment experience or 5MeO-DMT:

Therapeutic (PTSD, Anxiety, Depression, Spiritual Growth)AlcoholOpioidsFentanylMethamphetamineBenzosKratomOther prescriptions or street drugs

Do you have any allergies?

Are there any legal problems (bail, probation, parole) that would restrict your ability to travel abroad?

YesNo

Explain:

Pre-existing medical condition(s), surgeries/procedures:

Any special dietary considerations:

Please list all prescribed medication, drugs, or supplements you are currently taking, or have taken in the past six (6) months. Include dosage, frequency, method, and length of use:

Any history of cardiac problems/surgeries, diabetes, hypertension/high blood pressure?

Pre-existing mental health issue(s), including mood disorder(s):

Have you had EKG and bloodwork (liver enzymes, magnesium levels) in the last 30 days?

No. (No problem; we will do these tests when you arrive at our facility.)Yes. (Please arrange to send a copy to admin@newpathibogaine.com, dr.silva@newpathibogaine.com )

Please describe your history (if any) with psychedelics, and when:

AyahuascaEcstasyKetamineL.S.D.MescalineMDMAMushroomsPeyotePsilocybinOther

Describe when:

Would you describe your past psychedelic experience(s) as positive or negative? Please explain

Have you ever had hallucinations or a psychotic episode, whether connected with psychedelics or not?

Do you have any history of a mental health diagnosis, psychiatric admissions, suicidal ideations/attempts?

Are there any relatives who have a history of mental health issues, including psychiatric admissions and suicidal ideations/attempts?

Have you ever experienced paranoia, or a nervous breakdown due to stress or burnout?

Are you seeking to resolve any history of belligerent or assaultive behaviour, whether under the influence or not?

Attach files

Financial confirmation:

I can meet the financial obligations required for treatment.I am unable to meet the financial obligations required for treatment at this time.

Please explain how you came to know about New Path:

Alumni referralInternet searchFacebookInstagramYouTubeOther

Get In Touch