February 18 ~ March 11, 2026 Application & Health Intake Form.
February 18 ~ March 11, 2026
Sign in to Google to save your progress. Learn more
Email *
The Ayurveda India Retreat features 21 days at an Ayurvedic retreat in the Nilgiri Mountains of South Central India, where you will receive first class care with our gifted Ayurvedic physician and his team of Ayurvedic therapists and chefs. The retreat also highlights yoga, meditation, music, storytelling, group work, nature walks, and daily visits with our Ayurvedic doctor. As a 21-day Panchakarma, the retreat is focused on identifying imbalances and detoxification of the body using herbs, diet, and numerous kinds of Ayurvedic treatments including massage, steam, deep tissue, shirodhara, nasal oil, enema, herbal preparations, and so much more! Please read the detailed section below to better understand Panchakarma and the overall intention of this healing retreat with us.
Panchakarma (PK) is the umbrella term for a variety of Ayurvedic cleansing practices and treatments intended to rebalance the body, mind, and spirit. It is based on the Ayurvedic principle that every human is a unique blend of  the five basic elements of Ether, Air, Fire, Water, and Earth.

The combination of these elements funnel into three doshas: Vata, Pitta, and Kapha, and their balance is unique to each individual. For example, I may have more fire element in my nature, and this means I am largely Pitta. Someone else may have more earth and water element in their true nature, which means they are more Kapha by nature. Another person may have more air and ether in their constitution, making them predominantly Vata. When our true nature is out of balance, we say the doshic balance is disturbed, and this imbalance is what creates disorder in our body, mind, and spirit and can result in disease.

At Mountaintop Clinic, Panchakarma is done individually for each person with their specific constitution and specific disorder in mind, thus it requires close observation and supervision. Treatment starts with pre-purification (purgation), followed by both rejuvenating and cleansing methods we call "Rasayana." The minimum amount of time to engage in this protocol is 21 days. The beauty of participating in a guided retreat is that we have the unique support of a shared group experience, as well as two seasoned facilitators (Katie & John) to hold the container, offering time for group process, questions, practices like yoga, meditation, music, and story, as well as integration after the retreat has concluded.
A brief health history will help us to determine whether this retreat is a good fit for the applicant, as well as for us to best support you on your journey into Panchakarma. Dr. Sundara Raman offers his assessment of you, your health, and the best blend of herbs and PK therapies to help reduce imbalances and help return you to homeostasis in the time you are spending at the retreat. Coupled with our yoga and meditation program, opportunities to sing, walk, and breathe fresh mountain air, we hope this retreat will be a transformational experience that positively impacts your physical, mental, and spiritual health!

By selecting "YES" below, you acknowledge that this is a medical retreat, not a tourist trip, and that you are willing to join us on an incredible health journey!
 *
Those who have attended this retreat in the past two years are welcome to join us for an extra "early" week, Feb. 11-Feb. 18. Please indicate below that you are interested in the extra "early" week option.
Clear selection
Please share the following information about yourself, your health, and your practice:
Full Name *
Cell Phone # *
Street Address *
City / Town / State *
Zip Code *
If your mailing address is different than above, please write it here: 
Age *
Sex *
Dosha (if you know) *
Occupation
What do you do for recreation? *
Why would you like to attend this retreat? *
How did you learn about this retreat? (and please indicate if you have attended this retreat with Katie & John previously). *
Are you presently taking any medication? If so, which ones? *
Are you presently under the care of a medical doctor or health practitioner? If yes, for what reasons? *
Have you ever done panchakarma before? If so, with whom, at what facility, and what treatments? (If with Katie & John, please indicate what year(s) you attended. *
Do you have any restrictions in movement? *
What physical activities do you normally participate in? *
Please list any recent surgeries, accidents, or injuries: *
Please indicate if you suffer from any of the conditions listed below *
Required
Please explain any of the conditions checked above. *
Briefly describe your yoga practice including years of practice, styles, and frequency (you do not have to practice yoga to attend this retreat): *
This retreat is more than a simple R&R vacation; we are here to experience a deep dive into our health, and this includes taking herbs, eating a vegetarian diet, Ayurvedic bodywork, daily meetings with the doctor who offers diagnostics including pulse and tongue, as well as blood labs to better assess current health and consider treatment of current imbalances. Although you will have some cultural opportunities as a part of this retreat, our experience is not a tour or travel retreat. Your answer below indicates your understanding of the scope of this retreat as a panchakarma, not a travel vacation. *
*HEALTH and YOGA Notes: In addition to the healing panchakarma that is the focus of the retreat, our program will include hatha yoga classes, yoga nidra, meditation, storytelling, music, and themed discussions/presentations, as well as excursions to town, all of which are optional.  As with any physical activity, yoga comes with inherent health risks.  During this retreat we are living at 6,000 feet above sea level, so please let us know if you have issues regarding altitude.
*OVERALL WELLNESS & Travel Health:  It is important to us that retreat-goers be in good physical condition, are able to fly safely, go on moderate walks, and do healing yoga. The retreat is at 6,000 feet elevation and there are numerous stairs to climb at the center. Your signature below indicates that you are attending this trip in good health, and are able to participate in appropriate deep healing Panchakarma practices for your body. In no way, shape, or form will John de Kadt or Katie O'Connell be held responsible for any injury or health issue that arises during or after the retreat, whether it is related to the content of the program or otherwise.  Please sign to indicate your understanding of the above. In signing you also offer us permission to share your health form with the Ayurvedic Doctor and Pharmacist at the center.
*ACCOMMODATIONS: Mountaintop is an intimate center with ten simple but beautiful rooms. We offer preference to applicants who are willing to share a room with a partner, family member, friend, or another guest. Please see the description of our rooms on the website to acquaint yourself with the spaces and amenities. Rates as listed are all inclusive of panchakarma, twice daily treatments (massage, oil baths, steam, etc.), herbal medicines, lodging, meals, comprehensive lectures on Ayurveda, yoga, meditation, music & story, excursions to town, and daily consultations with the doctor, and more. Due to limited availability of single rooms, those willing to share a room are given preference during the application process. Previous attendees are eligible to add a 4th week to the experience once the 3-week retreat fees are paid in full. We strongly suggest you purchase trip insurance that covers the entire cost of your retreat and flights..

*Shared double rates in  STANDARD ROOM; shared Double Bed: $4,875 per person. Please secure your own roommate.

*Shared double rates in TRIBAL HUT ROOM; 1 King / 1 Queen Bed: $5,575 per person. ONLY ONE HUT AVAILABLE. Inquire for triple rates.

*Single rate in PRIVATE STANDARD ROOM: $5,875. 
*Single rate in PRIVATE ECONOMY ROOM: $5,475

 *
If sharing a room, please write roommate's FULL NAME here:
Electronic Signature *
Please feel free to share anything else about yourself and your wishes for this trip:
We will be in touch to let you know if your application has been approved!
Thank you for submitting an application to our Healing Retreat to India. You can contact your hosts, John and Katie by phone or email with any questions you might have.
John de Kadt: johndekadt@gmail.com, (413) 717-1711
Katie O’Connell, Dragonfly Yoga & Ayurveda, dragonflyoga@gmail.com, (603) 707-7529
By clicking "Submit" you agree to all terms and conditions of this waiver.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms