Application To Attend Inscape Program — INSCAPE RECOVERY

INSCAPE APPLICATION

Name

First Name

Last Name

Birthday

YYYY

Contact Info (City or town and country in which you currently live / phone number / email address)

Emergency contact name and number

For what issue(s) are you seeking treatment? / Are you seeking primary treatment or ibogaine aftercare? / Have you been in another treatment program before? Please specify

When would you like to begin treatment?

Have you ever been diagnosed with a mental health disorder? Please specify what and when / Have you considered suicide in the last six months?

Do you have any physical health issues -- illness, extreme allergy, physical limitation, pain or injury? Please specify. / Have you ever been hospitalized for illness, injury or other reason? Please specify what and when / Is there any illness that runs in your family that we need to consider? Please specify

Have you been involved in a violent incident within the last 3 months? If yes, please specify

Please list all drugs (including street drugs, alcohol and all prescription medications, psychoactive and non-psychoactive) that you have consumed within the last three months, and frequency of consumption:

Are you currently involved in any legal process? If yes, please explain as much as possible

What motivates you to seek treatment (ie - What is your treatment goal?)

How did you hear about us?

Additional info/comments?