This free survey is powered by
QUESTIONPRO.COM
Create a Survey
Surveys
2011
March
S
Survey
Survey
0%
Exit Survey »
Please type in your birthdate.
--
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--
2024
Please indicate your race/ethnicity.
Please indicate your gender.
Female
Male
Other
What is the highest level of education you have completed?
Some high school
Completed high school
GED
Some college
Technical certification
Associate Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
What is your current martial status?
Single
Married
Separated
Divorced
Widowed
Living together/cohabitating
Other
What was your martial status at the time of Ibogaire treatment?
Single
Married
Separated
Divorced
Widowed
Living together/cohabitating
Other
What is your yearly income?
What was your yearly income at the time of Ibogaire treatment?
What is your religious affiliation, if any?
-- Select --
Protestant
Catholic
LDS/Mormon
Muslism
Budhist
E. Orthodox
Unitarian
Jewish
Hindu
No preference/no religious affiliation
Other
How would you describe your current employment status?
Employed full time
Employed part time
Unmployed
Student
Homemaker
Retired
Loading...
close
Loading...
Close
qpweb1.questionpro.net
Loading...
