The Courage to Grow - retreat application form

Welcome to the application form for The Courage to Grow Retreat on August 23 - 27, 2023. This form is designed to gather important information about you, your health, your medical history, and your reasons for attending. Please answer the following questions as accurately and completely as possible. All information will be kept confidential and will not be shared beyond the retreat leaders and breathwork facilitator.

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Welcome!
Your name *
Age *
Gender *
Do you identify as BIPOC? *
Phone number *
Email address *
Social media handles *
How did you hear about this retreat? *
If other, please specify further.
Accommodation type *
For shared or semi-private, do you have specific gender preferences for roommates? Please help us understand what you need. *
Food will be healthy-vegetarian. Do you have any food sensitivities? Please specify. If celiac, please note.
What is your main reason for wanting to attend this retreat? *
What is your intention? *
What do you hope to get out of it? *
Have you ever participated in breathwork before? If yes, please describe your experience.
 *
The retreat centre has varied terrain including a sizeable hill. Do you have any medical conditions or physical limitations that require our consideration when planning activities? If yes, please explain briefly. *
Are you currently taking any medications or supplements? If so, please list them. *
Have you ever been diagnosed with a respiratory or cardiovascular condition? If so, please describe your condition and any treatments you are currently undergoing.
 *
Have you experienced traumatic events in your life? If so, please describe the most significant ones briefly. *
Have you been diagnosed with any trauma-related disorders, such as PTSD? *
Do you feel like you have been impacted by cultural oppression? If so, what would help you feel safe and seen?
 *
Do you smoke, drink alcohol, or use any recreational drugs? If yes, please list substances and frequency of use. *
How would you describe your sleep patterns? Do you have trouble sleeping? *
How would you describe your diet and exercise habits? *
Do you experience any physical symptoms such as chronic pain, tension or digestive issues? If yes, please describe them briefly. *
Do you experience any emotional symptoms such as anxiety, depression, or mood swings?  
 *
Do you have any concerns or questions about the breathwork process?
 *
Are you comfortable lying down on your back for an extended period of time?
 *
To best support your wellbeing and self-authority, we ask you to please be willing to communicate to the retreat leaders if you are uncomfortable at any point during the retreat. Is this something you are willing to do and take responsibility for? *
Thank you for completing this application form. :)


Your responses will help us to better understand your needs. We look forward to sharing this profound and transformative journey with you!

Please let us know if you have any questions or concerns, and do not hesitate to reach out to christina@soulspringwellness.ca.

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