INTAKE FORM RETREATS

top of page

HOME
ABOUT
HUMAN
WORK
JOURNAL
More

Use tab to navigate through the menu items.

Apply now

Please note that the information you provide here will be protected and treated with the utmost confidentiality. These questions help me provide you with the safest environment and highest level of care I can. It is essential to the process that you answer with openness and honesty.

First Name

Last Name

Address

Country of Residence

Birthday

Code

Phone

Emergency contact name

Emergency contact phone number.

Gender

Please share, in a couple of sentences, your personal reasons and intentions for inquiring about a retreat? What conditions play a part in your life?

For how long have you been experiencing these challenges?

What have you tried already to help your situation?

Are you aware of any sexual, physical or emotional abuse in your past? If yes, can you tell us more about this?

Do you have any allergies?

Is there anything else that is important for us to know?

What do you want to receive from this retreat?

Please select from below the services you would like to explore

Embodying presence workshop 200$

Goal setting & Mind mapping workshop 400$

Innerchild workshop 500$

Understanding psychological conditioning workshop 550$

CBT process (Core beliefs) workshop 400$

Finding balance workshop 200$

Shamanic Alternative Medicine workshop 500$

Emotional release workshop 400$

Heart opening Cacao Ceremony 200$

Healing massage with Angelica Spa 90 min 120$

Mind Body Soul Detox Program (for the duration of the retreat) 1100$

Additional night stay with meals 180$

How many days you would like your retreat to be?

6 days

5 days

4 days

3 days

I don't know, please recommend

Are you currently taking or have you recently stopped taking (within the last year) any prescribed medication or anti-depressants?

How many alcoholic drinks do you normally consume each week?

Have you ever used street or recreational drugs (including Marijuana)?

Have you ever been diagnosed with, or treated for a drug or addiction? Please list any other addictions you have had or currently have.

How ready you feel to hear truth and face yourself?

It starts with an intuitive impulse that
leads to a conversation..

I WANT TO HEAR YOUR STORY

NETEN

Education and Alternative Therapy Center

Perez Zeledon

COSTA RICA

11901

bottom of page