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Weekend Intensive Intention Questionnaire
Welcome!
By filling out this form, you are taking the first step in a unique life experience and one-of-a-kind transformational retreat.
Please answer the below questions to help clarify your intention with this experience and where you would like to travel to.
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* Indicates required question
Email
*
Your email
Full Legal Name (as displayed on passport)
*
Your answer
Phone Number
*
Your answer
Age
*
Your answer
Traveling From (City, Country) + Preferred Airport
*
Your answer
What is your intention in seeking this custom retreat experience? Be specific
*
Your answer
Where in the world would you like this retreat experience to be? Why?
*
Your answer
When would you like to have this retreat experience? List 3 preferred weekends (Friday - Sunday afternoon) in order of priority
*
Your answer
Which area does your chosen retreat experience feel most closely aligned with?
*
Spiritual & Personal Growth
Trauma/Grief Release
Plant Medicine Ceremony Therapy
Deep Relaxation & Reset
Fear Dissolution & Adventure Excursion
Other:
Accommodation Preference
(not guaranteed, but will do my best depending on location, availability, intention, and other factors)
*
Hotel
Airbnb
Other:
Which modalities interest you most as part of this experience?
*
1 (Not interested at all)
2
3
4
5 (Very Interested)
Massage therapy and bodywork
Plant medicine ceremony
Breathwork sessions
Meditation sessions/lessons
Reiki energy healing sessions
Coaching sessions
Angel Card Reading
Local Food & Restaurants
Experiences & Activities (i.e. zip-lining, volcano hikes, etc)
Cultural Exploration
Other (we can discuss live)
1 (Not interested at all)
2
3
4
5 (Very Interested)
Massage therapy and bodywork
Plant medicine ceremony
Breathwork sessions
Meditation sessions/lessons
Reiki energy healing sessions
Coaching sessions
Angel Card Reading
Local Food & Restaurants
Experiences & Activities (i.e. zip-lining, volcano hikes, etc)
Cultural Exploration
Other (we can discuss live)
Dietary restrictions, physical health concerns, or other allergies/medications I should be aware of?
*
Your answer
Emergency Contact - Name / Phone Number / Email
*
Your answer
I confirm that my passport or travel document is valid until at least 6 months from the END of the planned retreat
*
Yes
No
Anything else you would like to share at this time?
Your answer
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