Sacred Center LIVE Intake Form

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Please fill out the following prior to attending the retreat

Email *

Full Name *

Date of Birth *

YYYY

Medical History: Please list all past injuries, surgeries, illnesses or other experiences that have impacted your health and well being and if you require extra assistance for a yoga/movement practice. *

Are you still menstruating? *

Have you had any major events related to/around your pelvic bowl? Pregnancy, surgery, cancer, sexual trauma, fall to the tailbone, etc. *

Yes

Required

If you answered "yes" to the above question, please explain how this event has impacted your life/relationships, what healing practices you have done (if any), and what work you still feel has yet to be done to heal this area physically and energetically. *

What are you hoping to take away from attending this retreat? *

Are you ready, willing, and able to be fully present with yourself and the group during all discussion and movement practices? *

Yes

Required

Are you ready, willing, and able to attend sessions on time? Friday and Saturday begin at 8 a.m. *

Yes

Required

Have you participated in a yoga and/or women's retreat before? If yes, what did you find most beneficial? What would you have liked more or less of?

How would you describe your current stress level?

Low

Moderate

High

Clear selection

Are you currently seeking mental health for psychological support? If yes, please provide a note of clearance for attending this retreat as some practices are intentionally designed to stir up and release emotions. *

Please add anything else you feel is pertinent in attending this retreat.

Send me a copy of my responses.

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