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Pre-Screening
Email *
Name *
Email *
Address *
Phone number *
Emergency contact *
Whatsapp number with international dialing code
Age *
Gender
Motivations for attending *
If requesting a personal retreat, list your date preferences
For Group Retreats: list your room preference (single, double or triple)
For Personal Retreats: list your accommodation preference (economic, mid-range, luxury)
 *
Do you take any of the following types of medications? List brand and generic names: SSRI's, SNRI's, anti-psychotics, anticonvulsants, stimulants, anti-anxiety *
Medical details regarding above medications *
Supplements- particularly those affecting mood *
Do you have any medical conditions? Do you medicate for them? *
Do you have bipolar disorder or have you had manic episodes? If so, please give details *
Do you have any psychiatric conditions? If yes, please give details *
Do you or any of your family members have a history of psychosis or schizophrenia? If so, please explain *
Have you ever attempted suicide, felt suicidal or had suicidal ideation in the last 5 years? If so, when and please give details *
Are you going through a major life crisis or major stressful life event that could be very challenging e.g. bereavement/breakup. If so, please give details  *
I am OK being touched appropriately by a facilitator if necessary *
Required
I am aware that withholding or misrepresenting any information relevant to this process can put me or others at risk and can prevent my participation in the retreat  *
I agree to read, sign and return the Participant Release & Waiver of Liability Agreement and Fitness to Participate Declaration a minimum of 14 days before the retreat
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