REMEMBER Plant Medicine & Feminine Embodiment Retreat Application Form

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What is your full name?* This field is required.
First Name
Last Name
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What’s your date of birth?* This field is required.
Date of Birth
Month
Day
Year
3
Please provide your WhatsApp Phone Number* This field is required.
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Phone
4
Please share your Email* This field is required.
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5
How did you hear about the "Remember" Plant Medicine & Feminine Embodiment Retreat?* This field is required.
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What called you to attend our "Remember" Retreat?* This field is required.
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Have you had any experiences working with plant medicines and/ or breathwork? (please share as much as you want)* This field is required.
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What would you like to get out of the "Remember" retreat?* This field is required.
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How would you describe the current state of your mental, physical and emotional health?* This field is required.
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Do you have any health conditions or concerns? * This field is required.
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Are you taking any over the counter or prescription medication?* This field is required.
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Please list all over the counter or prescription medication you are currently taking* This field is required.
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Have you had the mRNA Covid vaccination?* This field is required.
YESNO
14
How many mRNA COVID vaccines have you taken?* This field is required.
Please Select
Please Select
1
2
3
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15
What was the date of your last mRNA COVID vaccine?* This field is required.
Date
Month
Day
Year
16
Do you use any recreational drugs?* This field is required.
YESNO
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List any recreational drugs you use* This field is required.
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Is there anything else you would like us to know?
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How ready are you to make this investment in yourself?* This field is required.
I'm ready, it's a full body YES!
I'm ready but I may need an extended payment plan to make it work for me
I'm not ready and don't see myself being ready for this retreat
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Thank you so much for taking the time to complete "The Remember Retreat Application form". Before we invite anyone to join our retreats, we feel called to connect with you over Zoom. This is really a chance for us to see if our retreats are the right fit for you, for you to be able to connect with our energy and ensure we are the right facilitators and Medicine Women to guide you through this magical and expansive journey and for us to answer any questions you may have.

Click "NEXT" to book your appointment.
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Book a 30 minute connection call with us below* This field is required.
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