Applicant History Form

Please be sure to fill out this form as accurately and fully as possible.

Name *
Email Address *
Address
City
State
Zip
Age
Height
Weight
Phone
Emergency Contact
Do you smoke?
How long have you smoked?
How much do you smoke?
Do you drink alcohol?
How much and how frequently do you drink?
Do you have special dietary needs? (vegetarian, etc)
Do you have any allergies? (medications, food etc.)
Have you ever received a blood transfusion?
How long ago?
Why was it indicated?
Do you have any of the following conditions?
Please list all prior surgeries and dates
Please list all medications that you have taken in the past six months
What is the highest level of education that you have completed?
Do you work? If so, where and what do you do?
Whom do you live with?
Where did you grow up?
Whom did you grow up with (Mom, dad, brothers, sisters etc.)?
Write a brief history of your substance use and previous drug treatments, including how many times you have been in treatment.
When was your longest “clean” time? What did you do to maintain your recovery during that time? When was the last time you tried to get “clean”?
When you are experiencing withdrawal what have you found alleviates the withdrawal symptoms?
What are your hobbies? What do you like to do aside from use substances?
What types of exercise do you like? How often do you exercise? How would you describe your physical shape?
What are your spiritual beliefs/practices?
What are your current coping methods for addressing stress?
What are your greatest threats to sobriety?
What are your short, middle and long-term goals in life?
What are your short, middle and long-term goals for therapy?
Will you enroll in an aftercare program?
Do you have a healthy environment to return to?
Are you seeing a psychiatrist?

Do you Often, Sometimes or Seldom believe the following:
A) I really feel I need the approval of people I find important.
B) I can’t stand being stuck in traffic.
C) People absolutely must treat me with a minimum of respect.
D) Life has to be free of major hassles for me to be off of drugs.
E) I have to Succeed!
F) People who fail are failures.
G) Life sucks. It’s always one thing after another. What’s the use in trying so hard?
H) I get very upset if things don’t go my way when they clearly should.
I) To be happy I must know for sure that what I am doing is the right thing to do.
What else would you like our staff to know about you?
 

If you have any further questions, please let us know by calling us at 213-505-5992 or email: treatment@ibogaine-therapy.net