Name
*
First Name
Last Name
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Dietary requirements
An abundance of vegetarian dishes will be provided, hot and cold, savoury and sweet as well as snacks and drinks. The more we know beforehand the better we can cater to your preferences.
Please list the most important requirements first, then follow with any preferences.
Allergies
List any allergies here including food, insect bites, chemicals (like mosquito repellant /fly spray) etc…
Health / Medical History Form
Photography
*
I am happy to be in photos that are taken during the retreat.
1. Describe your physical state in general (e.g any aches/pains, weakness/ strengths, tightness /flexibility, fitness, weight, energy, nervous system regulation)
*
2. Do you have any health concerns (symptom or issue)?
3. What do you most hope to get out of your Retreat / Yoga Therapy session?
*
4. Please briefly list any current medications:
Type of diet (or concerns)
Sleep Patterns
Tobacco Use
Alcohol, drugs and related substances
Exercise / leisure activities
Home situation and significant other
Important experiences
Religious Beliefs
5. Please list any medical conditions or physical / emotional concerns?
6. Anything else you wish to communicate, ask or comment on?
Thank you!
We are looking forward to sharing yoga, nourishment, nature and friendship with you.
This retreat is about our inner-life and our natural wisdom that moves us toward deep healing. Om.
