Application Form Application Form Client Information Thank you for your interest in Medicine Spirit retreats. This application helps us understand your background, health status, and intentions to ensure our retreats are a good fit for your needs and that Iboga is safe for you. Important: Medicine Spirit offers psycho-spiritual retreats focused on personal growth and healing. We do not provide addiction detox services. If you're seeking to detox from substances, we can recommend appropriate medical facilities. This application takes approximately 15 minutes to complete. All information is kept strictly confidential. Name * Name First Name First Name Last Name Last Name Date of Birth * Gender * MaleFemaleNon-BinaryI prefer to self-declare Gender Phone Number * Email Address * Retreat Options Baja, Mexico April 25 to 29Baja, Mexico April 29 to May 3Portugal May 31 to June 4Portugal July 2 to 6 Retreat Options Do you have any dietary restrictions or preferences? Please list below. Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Emergency Contact Emergency Contact Name * Emergency Contact Name First Name First Name Last Name Last Name Relationship * MotherFatherGuardianSister/BrotherPartner Email Emergency Contact Number * What draws you to work with Iboga at this time in your life? (100-200 words) What are your primary intentions or hopes for this retreat? (100-200 words) Are there specific patterns, challenges, or questions you're seeking clarity on? If you have prior plant medicine experience, please briefly describe context and key insights: Have you worked with any of the following? (check all that apply) Iboga/Ibogaine Ayahuasca Psilocybin mushrooms San Pedro/Huachuma Peyote LSD MDMA 5-MeO-DMT/Bufo Cannabis (ceremonial context) OtherOther If so, briefly describe your experiences. Are you currently taking any of the following? (check all that apply) Antidepressants (SSRIs, SNRIs, TCAs, MAOIs, etc.) Anti-anxiety medications Mood stabilizers Antipsychotics Blood pressure medications Heart medications Pain medications Sleep aids OtherOther Do you have any known medical allergies? * No YesYes Please list ALL medications you are currently taking, including dosage: Any dietary information we should know: Please list all supplements, vitamins, and herbs you take regularly: Medical History Check the conditions you're currently experiencing: Chest Pain Cardiovascular Allergy Diabetes Fever Hematological Neurological Psychiatric Respiratory OtherOther Are you currently under medical treatment? * No YesYes Have you been admitted to hospital or had surgery within the last 2 years? * No Yes Do you use any kind of tobacco product? If yes, how often? * No YesYes Do you use any kind of illegal drugs or have you ever used them? * No YesYes How often do you consume alcohol? * DailyWeeklyMonthlyOccasionallyNever, don't drink Mental Health Check the conditions that apply to you: Depression Anxiety PTSD Bipolar Disorder Schizophrenia Personality Disorders Eating Disorder OtherOther If you checked any mental health conditions, please provide brief details: Have you ever been hospitalized for mental health reasons? Is there anything else you would like us to know about you? How did you hear about Medicine Spirit? Submit Start Over If you are human, leave this field blank.
