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High Vibe Bali Retreat
Please fill out this form and we will contact you about reserving your spot with a $500 none refundable deposit
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Full Name *
Date of Birth *
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Email *
Phone *
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What do you do for work?
How would you describe your overall health condition right now?
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Do you drink alcohol – If yes, how often? 
 Do you use recreational drugs – If yes, which kind? 
Do you smoke cannabis or vape – if yes, how often?
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Are you currently under a doctor’s care for any medical or mental-health condition? If yes, please describe: 
Have you experienced major stress, loss, or trauma in the past 12 months? If yes, what feels safe to share: 
What would you like to experience at the retreat?
Are there specific symptoms, patterns, or challenges you want to address?
Please list any food allergies or food restrictions
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