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 How did you hear about Medicine Spirit? Contact Information We prefer communication via Signal App, but can also do WhatsApp, phone text, and email. What is the best way to get ahold of you? Email Address * Phone Number * Signal Username WhatsApp # 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 Retreat Options * Baja, Mexico: May 7-14, 2026Portugal June 8-12, 2026Portugal July 3-6, 2026Portugal Sept 14-17, 2026OtherI'm interested in a Private Session Dietary Preferences Do you have any dietary preferences or restrictions?? Please list below. Do you have any food allergies or allergic reactions to any foods, insects, or anything else? Intentions 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? Medicine Experience It is not required to have any experience with other kinds of plant or psychedelics medicines in order to receive Iboga, but it is helpful for us to know if you have. Have you worked with any of the following? (check all that apply) Iboga Ibogaine Ayahuasca DMT Salvia Divinorum Psilocybin / Mushrooms Huachuma / San Pedro Cactus Peyote Bufo 5MEO Kambo Rapé (Hapé) Sananga LSD Ketamine Cannabis OtherOther When was the last time you took any of these Medicines? This is not relevant if it was very minimal use and long ago. It is more relevant if it was recent use (within the last year, was or is frequent use, or for over longer periods of time. If you have prior plant medicine experience, please briefly describe the context and key insights. Medications, Supplements, and Substances There are some medications, supplements, herbs, and street drugs that are contraindicated with Iboga. It is very important for us to know everything that you are taking, or have had a history with. Failure to disclose can put you at risk of heart rhythm disturbances, serotonin syndrome, and other things. Honest disclosure is for yours and everyone’s safety, not a judgment. Are you currently taking any of the following? (check all that apply) Antidepressants (SSRIs, SNRIs, TCAs, MAOIs, etc.) Anti-anxiety medications Mood stabilizers Antipsychotics Amphetamines (Adderall, Vyvanse, Dexedrine, Evekeo) Blood pressure medications Heart medications Pain medications Sleep aids Hormonal & endocrine medications Venom-Based therapies (bee, snake, etc) OtherOther Please list ALL medications you are currently taking, including dosage. If taking nothing at all write N/A. * Have you taken or are you currently taking any of the following substances (check all that apply) Opioids (Heroin, Fentanyl, Oxycodone, Morphine, etc)) Kratom MDMA (ecstacy, molly) Cocaine / Crack Methamphetamine (Meth) Nitrous Oxide Benzodiazepines (Benzos, Valium) PCP Psychedelics & Strong Psychoactives (even microdosing) Alcohol OtherOther Are you presently taking any of the above substances? If so, please list them here including frequency of use, dosage, and describe your relationship with them. Has there been a time or periods in your life when you have been a frequent user of any of the above substances? If so please briefly describe. Please list all supplements, vitamins, and herbs you take regularly. If taking nothing at all write N/A. * How often do you consume alcohol? * DailyWeeklyMonthlyOccasionallyNever, don't drink Do you use any kind of tobacco product? If so, which kind and how often? * No YesYes Medical Information Do you have any known medical allergies? If so, pleqase list them here. * No YesYes Are you currently under medical treatment? * No YesYes Check the conditions you are currently experiencing or that are diagnosed conditions: Chest Pain Fever Allergies Respiratory Cardiovascular Psychiatric Neurological Hematological Epilepsy Seizures Diabetes Parkinsons Auto-Immune Disease Traumatic Brain Injury PTSD OtherOther Have you been admitted to hospital or had surgery within the last 2 years? No Yes 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 some more details: Have you ever been hospitalized for mental health reasons? If so, please share a little more Emergency Contact Name * Name First Name First Name Last Name Last Name Phone * Is there anything else you would like us to know about you? Submit Start Over If you are human, leave this field blank.
