INTAKE FORM RETREATS

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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 required

Phone

Emergency contact name

Emergency contact phone number.

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?

In which month/days you would like to attend?

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?

Are you ready to invest in changing your life? Do you have a budget for it?

DISCLAIMER

The information on this site is for educational purposes and isn’t a substitute for professional medical advice. Your health and safety are our main concerns, so please consult with your doctor or a healthcare provider if you have any questions. Keep in mind that individual results can vary.