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Interest Form
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Email
*
Your email
Which retreat are you interested in:
*
Couples retreat - June 14th -17th 2024
Therapist self-care retreat August 9th- 12th, 2024
Holistic Wellness retreat August 8th- 12th, 2024
Other:
Required
Name (First and Last)
*
Your answer
DOB
*
Your answer
Phone number
*
Your answer
If you are bringing someone to the retreat, please indicate
NAME
,
DOB
, and
EMAIL
address of person coming with you. They will be required to fill out separate forms.
*
Your answer
How did you hear about Healing Escapes retreats?
*
Your answer
Have you attended other retreats in the past? If so, which ones and how was your experience?
Your answer
Would you like to schedule a 1:1 phone consult to get more information - if so, specify days/time available to talk
Your answer
Registration is on a 1st come, 1st serve basis - Are you ready to book your retreat spot? (Check all that apply)
*
I'm ready to register and will complete the Screening Questionnaire shortly for further consideration
I am ready to register and will pay the deposit to secure my spot using the secure pay link shortly...
I am ready to register and will pay in full to secure my spot via the secure Link on the website shortly
Please contact me as I have some questions before I submit payment
Other:
Required
Discount/Referral Code
Your answer
If you know of anyone else who may be interested and you'd like for us to contact, please indicate below.
Name:
Email:
Phone Number:
Your answer
A copy of your responses will be emailed to the address you provided.
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