E M B O D I E D : A Women's Retreat Application

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Email *

Name *

How did you hear about The Embodied Woman’s Retreat? *

Are you interested in reserving a shared, private, or outdoor tent space? If you are looking to reserve a shared space, do you have someone that you wish to reserve the room with? *

Have you attended a retreat, workshop, or ceremony, hosted by one of our facilitators in the past? Which facilitator? *

What is your intention in joining The Embodied Woman’s Retreat? What do you hope to receive, develop, or expand upon in your time with us? *

What is your current relationship to song, dance, and expression? Please briefly emphasize something specific that you are seeking to explore. *

Please share something that you are currently working through, seeking to transform within yourself. *

Some of our healing modalities and creative exercises involve body work, physical adjustments, and touch. How comfortable are you with physical contact? *

Do you have any experience with ceremonial medicines? If yes, please briefly describe which medicines, your experience or relationship with these medicines. *

Ceremony of Kambô (Amazonian frog medicine) will be offered the morning of July 17th for an additional 50 dollars. Are you interested in participating in this ceremony / would you like to receive more information on this medicine? *

Would you like to invest in the optional spa package for $150? *

Yes

If you chose yes for spa, Which mask would you prefer ?

Clean Green Mask: (Aloe, honey , carrots seed oil, mooring , frankincense EO, Chamomile EO)

Black Oat Mask: (Honey, Carrot seed oil, activated charcoal, oats, lavender EO, Helichrysum EO)

Clear selection

For the spa, which bath option ?

REJUVENATING : Hibiscus flower, rose hip, and sage herbal infusion, oat milk, ginger essential oil, and Salt from the Dead Sea. This bath is garnished with orange slices and fresh mint.

RELAXING : Butterfly Pea Flower, Chamomile, and Sage herbal infusion, oat milk, vetiver root essential oil and salt from the Dead Sea. This bath is garnished with Lily flowers & Lavender.

Clear selection

Do you have any food allergies or preferences? Are you sensitive to particular scents or sacred smudges? *

Have you tested positive or been exposed to COVID in the last 14 days? *

Do you have any physical injuries, disabilities, or have you undergone any surgical procedures that we should know about? *

Do you have a history of mental illness or a genetic disposition to mental illness? *

Are you taking any medication ? If so , please state which one . This does not make you exempt from this retreat or any of the activities involved (maybe Kambo) , this is just for our awareness. Thank you ! *

Please provide an emergency contact. Include their name, number, and your relationship to this person. *

Are you prepared to financially invest in this transformative journey, for your creative expansion and embodiment? *

After you make the deposit of $150 to reserve your space (Non-refundable), Which Payment Plan would you prefer ? We are willing to be flexible under special circumstances as long as all payments are due by the day of the retreat. This will qualify for only special needs. Just tell us in the interview process. (3 spaces total) *

FULL (Due after the interview)

Half ( Half due after the interview , Half due 7/9)

Three Parts (After the interview, 7/9 , & Arrival of retreat )

Special Needs (3 spaces total )

Please let us know a convenient time for you to undergo a brief interview process with one of our facilitators and the best way to contact you. Format: (Phone number, email, date, time). *

Any other questions, comments or concerns are welcome here. Thank You !

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