Apply For Ibogaine Treatment Online

Ready to take the first step towards freedom from addiction and trauma?Apply for Ibogaine treatment today by filling out the form below .

Please fill out the form below and our treatment team will get back with you.

First Name

Last Name

Phone Number

Date of Birth

Height

Weight

list any and all substances currently taking

Reason for seeking treatment

Please list any and all pre existing conditions

When the reservation is made at least 12 weeks in advance

When the reservation is made at least 8 weeks in advance

When the reservation is made at least 4 weeks in advance