Inner Illuminations Registration Form
Please fill in this form if you are ready to register for

Inner Illumination

An Akashic Records Medicine Retreat
with Calista Goh, Claire Eli & Noel Tuan

AKASHIC RECORDS . PLANT MEDICINE . SHAMANISM . YOGA . MOVEMENT

Sacred Valley, Peru
September 15-25, 2020
First Name *
Last Name *
Email Address *
Telephone Number (Please include country code) *
WhatsApp Number (Please include country code)
Country *
Accommodation Type (Early Bird Price before 1 May 2020 + US$ 200 thereafter) *
Emergency Contact Person *
Emergency Contact Relationship *
Emergency Contact Telephone Number (Please include country code) *
What attracted you to this Retreat? *
Do you have experience in working with the Akashic Records? *
What previous experiences have you had working with plant medicines? *
Do you have any experience or related training in Spirituality or Spiritual Practices (e.g meditation, yoga)? Do you maintain a regular practice? *
Do you have any of the following medical conditions? *
Required
Have you ever been diagnosed with the following mental conditions? *
Required
Do you have any allergies, dietary constraints or health/physical challenges? Please provide details. *
Might you be pregnant at the time of the Retreat? *
Are you on any medication? If so please list medication and reason for use. Please note that it is imperative that you list all meditations, as the plant medicine can interact with certain medications in a way that can be dangerous. *
Have you ever taken SSRI (Selective Serotonin Reuptake Inhibitors) medication for depression? If so when? For how long? *
Please select if you have you used any of these recreational substances in the past 6 months?
If yes, please describe context and frequency of use.
Would you say you have either a alcohol or drug dependency? *
Have you ever been a victim of physical or sexual abuse? We realize that this is a sensitive matter. It is important for us to know the extent and severity of these experiences so we can support you in the best way possible during your work with the medicine. *
How did you hear about this Retreat? *
Is there anything you would like to share with the organizers? E.g. Wanting to come and stay together with your partner.
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy