Confidential intake

Founding cohort application

This starts the process — not a guarantee of admission, dates, or documentary selection. A human reviews every submission. Do not use this form for medical emergencies.

Application submitted.

A copy was also saved in this browser. If email delivery is pending first-time confirmation, you may also receive a prompt from the form provider — check spam. We’ll follow up manually.

I am applying as *

Prospective participant Family / support person Referring professional

Your name *

Email *

Phone / WhatsApp

City / region

Funding path interest *

Timing preference

Primary substances / concerns

Prior treatment?

What should we know? * Don’t include full SSNs, insurance IDs, or unnecessary medical record dumps here.

Documentary interest (Watch The Clearing)

How did you hear about us?

I understand this is not emergency care, not a guarantee of admission or outcome, and that ibogaine involves serious medical risks requiring screening. *

Secure form → info@clearibogaine.com