Welcome and thank you for your interest in the Yemanja Goddess Retreat. Completing this registration form is the first step in the process. Please note your registration is not complete until deposit is made!
Salvador, Bahia, Brazil
January 29 - February 5, 2023
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Name *
Email Address *
Date Of Birth *
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Emergency Contact *
Will you be carrying any legal prescription medications with you? *
Room Selection: *
Have you been diagnosed by a Psychotherapist or Psychiatrist?  If so, what diagnosis? *
Are you under the care of a Psychiatrist or Therapist?
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Are you taking medications? If so, what? *
Are you an abuse survivor? If so, what are some of your known triggers? *
How did you hear of this retreat? *
What would you like to receive from this retreat? *
Dietary Restrictions: *
To participate in this retreat a $500 deposit can be made via Cashapp: $ReneeMAdolphe or Paypal: retreatswithrenee@gmail.com (Please pay via friends and family or pay for a service and include the 5% tax rate). When do you plan to make the deposit? *
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