Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Email
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Country
(###)
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Referred by
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First Name
Last Name
Gender Identity & Preferred Pronouns
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Tell us a bit about your healing journey (this can be a high level of things like therapy, transformative experiences, spiritual explorations)
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Please list any areas where you feel stuck, blocked, or limited (emotionally, physically, spiritually, mentally, or in life).
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What are your intentions for the retreat?
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Any Medical Conditions
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List any medical conditions you have, and any medications or treatments you are engaged in to manage the conditions.
Of special note: heart conditions, blood pressure issues, diabetes, epilepsy, asthma, and other conditions may be contraindicated for this practice.
Write N/A if not applicable
Please list any past or current medical conditions or hospitalizations:
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Please explain the condition, illness, or accident and results of treatment. Write N/A if not applicable.
Please describe your mental health history.
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Have you ever been diagnosed with a personality disorder, schizoaffective disorder, bipolar disorder, or any other mental health conditions?
Please include substance abuse, addiction, eating disorders, PTSD, major trauma, specific diagnoses, and/or symptoms, if relevant (and whether current or past).
If so, please describe.
Are you receiving support, therapy, and/or treatments or any of the above?
Write N/A if not applicable.
Mental Health Symptoms
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Have you experienced Anxiety, Depression, Self harm, Intrusive thoughts or Suicide Ideation in the last 6 months?
If you have experienced any of the above, are you currently receiving treatment? Please explain.
Write N/A if not applicable.
Current Grief
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In the past 6 months, have you experienced extraordinary grief due to a break-up, a loss, or the death of a loved person or animal?
Are you receiving support, therapy, medications, and/or treatments for this experience?
Please explain.
Write N/A if not applicable.
Recent Traumatic Experiences
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Have you experienced physical, emotional, or psychological trauma in the past year? If so, please give a short description of what the traumatic experience involved, time frame, and approximate date. Also, your current relationship to the trauma.
Write N/A if not applicable.
Do you have a family history of severe mental illness (bi-polar, schizophrenia, DID, depersonalization)?
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Please describe and include your family member's relationship to you (i.e. mother, brother, grandmother, etc). Write N/A if none.
Are you taking any medications currently?
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If so, please list and include what they are for. If not write N/A.
Have you taken any medications in the last three months?
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If so, please list and include what they were for as well as date last taken. If none, write N/A.
Please list any supplements you are currently taking or which you have taken in the last three months.
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What is your experience with altered states if any?
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Please describe and include approximate dates and frequency as well as general experience (good, bad, fair), and any particularly good or bad experience. Or anything else you think we should know. If none, write N/A.
Date of Application
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MM
DD
YYYY
