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Ibogaine Clinical Pre-Screening Application (1)

"*" indicates required fields

1Introduction
2Personal Information
3Your Goals
4Practical Information
5Physical Health
6Medications
7Mental Health
8Substance Use
9Life Experiences
10Support & Aftercare
11Review & Submit
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Ibogaine Clinical Pre-Screening Application

Thank you for your interest in Inner Realms Center.

This confidential pre-screening application is the first step in determining whether our program is appropriate for you.

Please answer every question as honestly and completely as possible. Your responses will be reviewed only by our clinical team and treated with strict confidentiality.

Completing this application does not guarantee acceptance into the program, but it allows us to begin the clinical assessment process.

Confirmation 1*
Confirmation 2*
Sex Assigned at Birth*
Current Gender Identity*
Email Address*
Employment Status*
Relationship Status
Do you have children?
Emergency Contact Relationship*
How would you prefer Blair to contact you?*
Best Time to Contact You*

People come to Inner Realms Center for many different reasons.

The following questions help us better understand what brings you here, what you hope to achieve, and how we can best support you throughout the assessment process.

Which statement best describes why you are seeking treatment at Inner Realms Center?*
Are there any other areas you would also like to improve?
How long have you been experiencing the main issue that brings you to Inner Realms Center?*
Have you previously sought help for this issue?*
How ready do you currently feel to make meaningful changes in your life?*
1 = Not ready · 10 = Completely ready

The following questions help us understand any practical considerations that may influence your admission process or your ability to participate in the program.

Your answers do not affect the quality of care you will receive and are used only to help our team plan appropriately.

Do you currently have any legal matters that could affect your participation in this program?*
Do you currently hold a valid passport?*

We recommend beginning your passport application or renewal as early as possible to avoid delays should you decide to proceed with treatment.

Are you currently living in the country where you are a legal resident?*
Have you already considered how you plan to finance your treatment?*
If accepted into the program, would you currently be able to travel internationally?*
If accepted, when would you ideally like to begin treatment?*
How did you first hear about Inner Realms Center?*
Have you previously contacted Inner Realms Center?*
How would you prefer Blair to communicate with you after your application has been reviewed?*
You may select more than one.

Your safety is our highest priority.

The following questions help our clinical team identify any medical considerations and ensure that ibogaine treatment, if appropriate, can be delivered as safely as possible.

Some medical conditions do not necessarily prevent treatment but may require additional medical review or testing.

How would you describe your current physical health?*
Height unit*
Enter your height in the unit selected above.
Weight unit*
Enter your weight in the unit selected above.
Do you currently have a family physician or primary healthcare provider?*
Have you ever been diagnosed with high or low blood pressure?*
Is it currently well controlled?*
Have you ever been diagnosed with any of the following cardiovascular conditions?*
Have you ever had surgery?*
Have you ever been admitted to a hospital?*
Do you have any allergies?*
Allergy types
Have you ever been diagnosed with any of the following?*
Are you currently pregnant?*
Are you currently breastfeeding?*

Your safety depends on having a complete and accurate medication list.

Please include all prescription medications, over-the-counter medications, hormones, peptides, herbal products and vitamins that you currently use.

Some medications do not prevent treatment but may require adjustment before your arrival.

Are you currently taking any prescription medications?*
Prescription medications
Medication Name
Dose
Frequency
Reason for taking it
How long have you been taking it?
 
Do you regularly take any non-prescription medications?*
Examples: Ibuprofen, Tylenol, sleep aids, antihistamines, laxatives, heartburn medication.
Over-the-counter medications
Medication Name
Dose
Frequency
Reason for taking it
 
Are you currently using hormone therapy?*
Hormone details
Hormone
Dose
Frequency
Reason for use
 
Are you currently using peptides?*
Peptide details
Peptide
Dose
Frequency
Purpose
 
Do you currently use supplements, vitamins or herbal products?*
Supplement / vitamin / herbal product details
Product Name
Category (Supplement / Vitamin / Herbal Product / Other)
Dose
Frequency
Purpose
 
Have you started, stopped or changed any medication during the last three months?*
Have you ever experienced an allergic reaction to a medication?*
Have you ever been asked to discontinue medications before a previous psychedelic or ibogaine treatment?*
If our medical team recommends adjusting or discontinuing certain medications before treatment, would you be willing to do so under the supervision of your prescribing physician?*

Your emotional and psychological well-being is an important part of our assessment.

Many people seeking treatment have experienced depression, anxiety, trauma, grief, burnout or other emotional challenges.

Your answers help our clinical team determine whether our program is appropriate and how we can best support you.

How would you describe your current mental health?*
Have you ever been diagnosed by a healthcare professional with any of the following?*
Are you currently receiving support from a mental health professional?*
Which type(s)?
Have you ever been admitted to a psychiatric hospital or psychiatric unit?*
Have you ever experienced thoughts of ending your life?*
Have you ever acted on those thoughts or made a suicide attempt?*
Are you currently safe?*

If you believe you are in immediate danger or unable to keep yourself safe, please contact your local emergency services or crisis support service immediately. This form is not monitored continuously and is not an emergency service.

Have you ever intentionally harmed yourself without suicidal intent?*
Which of the following best describe what you are currently experiencing?*
Have you previously participated in psychotherapy or counselling?*
Which approaches have you tried?

Honest answers are essential for your safety.

There is no judgment attached to any of your responses.

Our goal is simply to understand your history and current situation so we can determine whether ibogaine treatment is appropriate and how to prepare it as safely as possible.

Are you currently using any of the following substances?*
How often do you currently use it?*
Route of administration
Have you previously struggled with substances that you no longer use?*
Have you previously received treatment for addiction or substance use?*
Type(s) of treatment
Have you ever experienced withdrawal symptoms?*
Symptoms experienced
Have you ever experienced an overdose?*
Have you previously used psychedelic substances?*
Which substances?
Have you ever previously received ibogaine treatment?*
How motivated do you currently feel to make lasting changes in your life?*
1 = Not motivated · 10 = Completely motivated

You only need to share what feels appropriate at this stage.

The following questions help our clinical team understand important life experiences that may be relevant to your treatment.

You are not expected to disclose anything you are not ready to discuss.

How would you describe your childhood environment?
Did you experience significant difficulties or trauma during childhood?
Have you experienced any of the following?
Do these experiences still affect your life today?
How do these experiences currently affect you?
Have you experienced any major life events that you believe are important for our clinical team to know about?
How ready do you currently feel to explore emotionally difficult experiences during treatment?*
Are there any topics you would prefer not to discuss at this stage?

Healing doesn't end when you leave Inner Realms Center.

Long-term outcomes are often influenced by the support, environment and resources available after treatment.

The following questions help us understand how we can best prepare you for this next stage of your journey.

Who currently provides emotional support in your life?*
Overall, how supported do you currently feel?*
Who knows that you are considering treatment at Inner Realms Center?*
How would you describe the environment you expect to return to after treatment?*
Do you currently have someone who can support your integration after treatment?*
Who?
Would you like Inner Realms Center to help you identify integration resources after your treatment?*
After returning home, how much time will you realistically have to focus on your recovery and integration?*

Thank you for taking the time to complete this assessment.

We understand that some of these questions may have been personal or difficult to answer.

Your responses will be treated with the highest level of confidentiality and will only be reviewed by members of our clinical team for the purpose of determining whether our program is safe and appropriate for you.

Completing this application does not guarantee acceptance into the program.

Accuracy Declaration*
Medical Updates*
Clinical Review*
I consent to being contacted by Inner Realms Center regarding my clinical assessment by:*
Privacy Policy*

What happens next?

  • Dr. Sue will carefully review your Clinical Pre-Screening Application.
  • If appropriate, Blair will contact you to discuss the next steps and answer any initial questions.
  • You may then be invited to schedule a confidential video consultation with Garyth, our Clinical Director.
  • Every application is reviewed individually. Our priority is always to determine whether our program is both safe and appropriate for your unique circumstances.
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  • About us
    • Our team
  • Treatment and Cost
  • Ibogaine
  • 5-MeO-DMT
  • Integration
  • Travel
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  • Testimonials
  • FAQ
  • Contact