5 Elements Info & Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for applying for these very special detoxification retreats with Laurel & the 5 Elements team!

Some of the elements of the retreat have medication & health condition considerations, please fill out each question and if any issues are raised we will get straight back to you.

Please book in via the available retreat dates and your deposit invoice will be generated, deposits on booking these strictly limited retreat spaces will confirm your booking.

Name: *

Your email: *

Telephone number: *

Are you taking any prescription medications or herbal or vitamin supplements? *

Yes (please list in the next section)

Medications & supplement list (if applicable) *

General Health: Please list any health conditions or issues here

Why are you interested in attending this retreat? *

We are offering Purification Sweatlodge (Lakota Native American Style) ceremony(s) as part of this retreat. *

This will be my first experience

I have experienced a Sweatlodge ceremony in the past

DIET: The 5 Elements retreat is designed as a cellular cleanse based on naturopathic principles. Please nominate the level of dietary detoxification programme that interests you. Note: the final day is a plant-based Phase Out, and we also have specific teas, and other naturopathic/herbal processes throughout the detox. PLEASE CHOOSE THE LEVEL OF YOUR CLEANSE *

Strong Cleanse: Organic vegetable juice fasting on arrival (2.5L)to Phase Out on afternoon of final day (total 4 days of 2.5L per day)

Medium Cleanse: Organic vegetable juice fasting (2L per day) , add hot soup/broth each evening

All 5 Elements participants will receive a complimentary naturopathic consultation (phone, zoom or in person) prior to the retreat so that every aspect of your health is considered during the retreat. Please tick all that apply to you and please nominate your prefered consultation mode *

Food cravings, for example: carbohydrates, bread, chocolate, sugar

Daily caffeine intake (includes green tea/matcha)

Marihuana intake every week (or more often)

Alcohol intake every week (or more often)

Pre-retreat consultation: I'd like a Zoom appointment please

Pre-retreat consultation: I'd like to see you in person

Required

COLONIC HYDROTHERAPY: A safe and efficient treatment to rid the colon of built up wastes and enhances the totality of the cleanse. This retreat requires 2 sessions with option for third (time permitting and at an extra charge). Some health conditions may contraindicate you for this treatment. *

I do not have colon cancer, or history of bowel surgery

I have not been diagnosed with Diverticulitis or any inflammatory bowel condition

Required

Here's an overview of therapies & group events included in 5 Elements Retreat

Ka huna bodywork 1.5hrs x 2

Morning yoga 1.5hrs x 4

Sauna (far infrared ) we suggest 2 x 25-min sessions per day

Morning ritual of herbal teas & gut cleansers

Colonic hydrotherapy sessions, 3 x 1hr sessions

Self directed Art Therapies for emotional wellness

Diet: 2 levels of organic vegetable juice fasting regimens

Take home pack including DIY cleansing information & recipes

Sound healing ceremony with ceremonial tobacco

Cacao Ceremony & sound healing on final evening

Group Breathwork Ceremony daily 2hrs

Daily check personal check in/out with team

Purification Sweatlodge on arrival, and at completion

Fee: $2900 residential live-in shared accommodation, maximum of 6 guests at any one retreat Each 5 Elements Detox Retreat has 1 x private QS accommodation with shared bathroom available at a slightly higher retreat rate. Please note: During the day the retreat has many private and serene personal spaces available for you to process and integrate what arises in the detox. *

I've read & understand the cancellation policy, I'm happy to share ($2,900)

I've read & understand the cancellation policy, I'd prefer to book the private room ($3,400) if it is available

Deposit of $500 is required on booking and an invoice is generated and sent to you upon clicking on one of the retreat dates below. Deposits are non-refundable (see covid exception) Cancellation policy: ALL additional payments (after the non-refundable deposit) become non-refundable within 30-days prior to your retreat start date, except where Covid-19 is impacting your ability to follow through with your 100% commitment to join in your specified retreat. *

I've read & understand the cancellation policy

This is my 100% commitment to joining 5 Elements Detox Retreat (choose one date below). By submitting this form I agree to pay my deposit within 48hrs or my space will be released to the next on the list. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms