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INSCAPE RECOVERY
Home
The Program
Program Overview
Services
Conditions we treat
To Qualify
After Inscape
About us
Staff
Location
Mission
On Addiction
Our Partners
FAQs
Gallery
Blog
Contact us
Apply Now
INSCAPE APPLICATION
Name
*
First Name
Last Name
Birthday
*
MM
DD
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?)
*
Additional info/comments?
Thank you!