2023 Private Retreat Request Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Select the preferred arrival date for your private retreat.* This field is required.This just gives me a general idea of when you'd like to come; it can be changed later.

Date

4

Select the preferred departure date for your private retreat.* This field is required.This just gives me a general idea of when you'd like to leave; it can be changed later.

Date

5

What would you like to work on? * This field is required.

If you're not sure, just give a few things that have attracted you to work with me

6

What is your top goal of our working together?* This field is required.

This just gives me a general idea of what we will work on; it can be changed later.

7

What are some areas/ways that you're currently accessing for your self work?* This field is required.

This just gives me a general idea of when you'd like to return: it can be changed later.

8

Are your dates flexible?* This field is required.

Yes

No

9

What is your departure city?

Where will you be flying from?

10

How many travelers?

11

What is your total budget for all travelers?* This field is required.This just gives me a general starting point and can always be changed later.

$2500 to $3500

$3500-5000

13

What kind of vibe are you looking for?* This field is required.Check all that apply!

Erotic

Rest and relaxation

Grounding and centering

Shamanic spiritual healing

Plant Medicine

14

What additional activities are you interested in?* This field is required.Check all that apply!

Beach and Water

Yoga and Tai Chi

Meditation and Journaling

Hiking and Nature

15

What else would you like me to know? * This field is required.

What else would you like me to know about your traveler's budget and/or travel preferences?