Apply for your iboga therapy

Do you want to book your own iboga session? Really? Do you really feel that way?

The procedure is as follows:

1. You will read the information: Iboga therapy and how to prepare
2. You fill out the questionnaire (below)
3. We will arrange on a specific date, we will answer all questions by WhatsApp or Signal or e-mail.
4. You will pay a contribution fee.
5. You will prepare according to the instructions (diet at least a week in advance)
6. You will arrive on the agreed date at the agreed place (usually Olomouc-Svatý Kopeček)
7. You will enjoy iboga in you ?Take time to relax and integrate after you return home.
8. We will have also few integration calls when you are back.

As a first step to learn more about you, I would like to ask you to fill out the questionnaire:

Online questionnaire on iboga therapy – first step to apply

Important instructions:

• All the information you write here, as well as everything I learn in the session, I consider strictly confidential.
• Please keep in mind that the more you tell me about yourself, the more effective assistance I can provide.
• If you do not wish to answer any of the questions, you must at least write “I do not answer”.
• Fill out the questionnaire no later than a week before the agreed date, so that I can prepare appropriately.
• You have reserved place for your therapy after paying a deposit of at least 100 EUR. The rest of the contribution should be paid at least 2 weeks before your date. The payment is irreversible if you cancel your participation later than 2 weeks before your date. Thanks for understanding.

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Name and Surname *

Your e-mail *

Fill your e-mail so we can stay in touch

Your WhatsApp (Signal) or phone *

I want iboga *

• At your place in Olomouc-Svaty Kopecek, Czech Republic
• Other place (fill below)

I want retreat

• 4-days shortened (I'm not addicted)
• Full 8-days retreat
• Other

Preferred date of therapy, possibly add other place *

We will agree on the exact date later. For now, please write when it's convenient for you

Your date of birth *

Place of residence (city and country) *

What is your body weight and height (for dosage purposes) *

What is your relationship with your parents? Describe shortly. *

What do you know about your birth (at least write whether it was by birth or caesarean section)? *

What is your relationship with your life partner (if you have) and your children? How old are they? *

How do you like to relax? *

What are you afraid of? *

Do you have any health problems? *

Are you under medical supervision? Yes (write reason) or write "No" *

Have you ever been hospitalized? *

Have you had surgery? Any accidents? *

Have you ever been hospitalized in a psychiatric hospital? If so, when and for what reason? *

Have you ever taken antidepressants? *

Please list the medications or dietary supplements you are taking now: *

How often do you use or have you used cigarettes, alcohol, hallucinogens, psychedelics or other "drugs"? How much, when and how often in the last few weeks? *

How do you eat (e.g. everything, vegetarian, vegan, raw food...) *

What is your current job? Do you like it? *

Why did you decide to do Iboga therapy with me? *

Do you have experience with other therapies? *

What physical or spiritual exercises do you practice regularly? (sport, yoga, meditation, etc.) *

Please write down any circumstances in your life that you consider important that have negatively affected you in some way. *

Write down your questions, expectations or concerns, write down how you feel. *

What is your most important intention for this session? *

I confirm that I have filled in everything truthfully *

• Yes

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