Costa Rica Family Information Form
Thank you so much for your interest in the Mindful Family Retreat in Dominical, Costa Rica, June 15-20, 2020.

Please fill out this form so we can get to know a little bit about you and your family as well as get a sense of any questions you might have for us. Stefanie will contact you within a few days after you submit this form to set up an initial phone call to make sure it is a good fit for all.
Email address *
Name *
Your answer
Phone Number *
Your answer
Please list the names and ages of everyone in your family. Let us know if anyone would not be attending the retreat. *
Your answer
What is your interest in the retreat? Do you think your other family members will be interested and open to it? *
Your answer
What is your family’s previous mindfulness experience? Please briefly describe it for each person individually. *
Your answer
Are there any mental health or health concerns for you or your family members that are important for us to know about or would get in the way of anyone participating fully in the retreat? Please be thoughtful when answering this question - it is important to be honest and express any potential concerns. Your answer is confidential. *
Your answer
Where do you currently live?
Your answer
How did you hear about the retreat?
Your answer
Do you have any questions for us? Please list them here:
Your answer
Thank you so much! Stefanie will be in touch shortly. We look forward to connecting with you soon.


Warmly,

Stefanie and Elisha
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