Retreat Intake FormSimply complete the form here and we will get back to you within 2 business days to set up a video call to explore this journey together.**All information shared is held completely confidential and solely for the purpose of making the most of our time together. Name * First Name Last Name Email * City + State Currently Living * Married? * Yes No If married, how long? Children? Yes No If yes, how many and what are their ages? Fully Vaccinated? * *vaccination is required to attend Vaccinated Vaccinated + Booster Please list any medications you are taking and why: * Please list any supplements you are taking and why: * What have you eaten/drank in the last 2 days? * Breakfast snack Lunch snack Dinner snack/dessert Top 5 favorite foods/meals Foods/drinks you avoid * Do you consume alcohol? * Yes No If yes, how frequently? How much at a time? Do you partake in any recreational drugs? * Yes No If yes, what and how frequently? Any Medical/Dietary Concerns:. * Please list any allergies, significant injuries (current and past), illnesses/diseases, etc. Do you exercise? * Yes No If yes, what forms of physical activity do you do and how often? Do you practice yoga? Yes No If yes, what style of yoga do you practice? What level of practitioner do you consider yourself to be? Beginner Beg/Int Intermediate Int/Adv Advanced Have you been on any sort of retreat previously? * Yes No If yes, what type of retreat was it and what did you gain? Anything else you'd like to share about a previous experience? How well do you feel physically? * How well do you feel emotionally? * Do you feel fulfilled in your current work? * Do you feel fulfilled in your current relationships? * What is calling you to attend this retreat now? * Looking forward to exploring the possibility of spending time in the jungle with you. I’ll be in touch within 2 business days.
