Retreat Application 
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Full Name  *
Email Address  *
Phone Number  *
Date of Birth *
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Emergency Contact  *

“This retreat is designed for those who are seeking a deeper level of personal well-being and who have already done some personal development.  Tell us about your healing journey and what you have explored.  What has helped you along the way and what did not resonate?



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What drew you to this retreat?
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Where does joy show up in your life? What brings you pleasure? What makes you laugh?
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What do you love about your life?
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What is missing in your life?
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Are you familiar with experiential therapy? If so, please describe your experience.  If not, what are you curious about? 


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What are you wanting to discover?
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What ignites your sense of wonder? 


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Do you have one or more established resources of support as you move into deeper personal work? (Ie. Bodywork, established therapist relationship, spiritual practice, etc.)


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Do you have a faith based or spiritual practice? If so, please describe.
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What is your history with therapy/counseling?  / treatment? dates ?


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Do you have any health conditions? please describe

List current medications.


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Food allergies or dietary preferences.


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Is there anything you would want us to be aware of that could enhance your retreat?
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A copy of your responses will be emailed to .
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