Registration Form
We are so glad that you decided to join the Conscious Intimacy weekend workshop!
 
Please fill out the form below to complete your registration.

We are asking you some personal questions – please answer them honestly to the degree that you feel comfortable. Opening ourselves to our deeper emotions can bring up a lot for anyone. This questionnaire allows us to assess the group's needs and boundaries, so that everyone can have a fulfilling and safe experience.

All answers are completely confidential and will only be seen by the facilitator Rike.
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Your full name *
Your email address *
Your phone number *
Your gender *
Emergency contact name + phone number *
Please provide the name and number of a trust friend or family member to call in case of emergency.
Dietary requirement (if any)
The workshops includes some physically active components and full body movement. Will this present any physical difficulties for you?
Do you have any current health issues or take any medications that can alter your state?
What is currently alive for you in the area of emotional connection, relating and intimacy? E.g. do you have specific issues with your current partner, have you recently ended a relationship, are you dating and exploring... ?
Are you currently dealing with any trauma or acute difficult emotions related to childhood experiences, relationships, intimacy or sex?
Do you have a history of seizures, delusions, psychiatric treatments, are you currently in pyschiatric treatment, or are you taking any psychiatric medication?
Is there anything else that you would like us to know?
How did you hear about this workshop?
Agreement: I agree to take full responsibility for the nature of my experience. As an adult, I agree to be responsible and respectful in my interactions with others. I will use clear direct verbal communications and if I am not comfortable with something, I will express my concerns clearly and directly to the facilitators and organizers. I agree to monitor my participation and not exceed my own physical and emotional limits. I assume all risk for my condition in this workshop due to any pre-existing physical or psychological conditions that I have. *
We're looking forward to the workshop with you!
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