SELF-LOVE RECREATE YOUR REALITY - MAGIC MIRROR RITUAL RETREAT IN BALI Questionnaire

Congratulations Kellie!

For taking your first step

How exciting to possibly welcome you in December !!!!

You listened to your inner guidance.

"Here we go, here we grow" - Emmanuelle Blanc

**IMPORTANT - for the greatest ease, it is highly recommended that you:

1) Fill out the below questionnaire from your laptop or computer.
If this page gets accidentally closed, you will lose your work.

2) Put aside quiet focused time to complete and submit this page with thorough answers in ONE sitting.

Sections on this page:

3) Filling out your application may take approx 10 to 20 minutes.

5) Don't be SHY, the questionnaire is very private between you and me.
I am not judgemental. It is all for your highest good

Getting to know you. the questionnaire, suggested packing list, guidelines, and release form. That’s it!

Full Name*

First NameLast Name

Cell phone #*

Area CodePhone Number

What'sapp #*

Area CodePhone Number

Date of Birth*

Current Occupation*

City & Country of Residence*

Website *

How did you find out about me? (e.g. from a friend, a referral from a client, etc. If you found this event through a Google or social media search, what was the phrase/keywords you used?)*

Have you participated in live events, workshops, seminars, if so what the main topic was? *

Please list any online courses you’ve participated in, what the topic was, whether you completed, and what the most valuable thing was from each one? *

What are the 3 oh YES, I want to work with Emmanuelle?*

Your WHY: What is the driving force behind your decision to come to BALI for your 1:1 in person retreat?*

Finish the sentence: To me, self-love means...*

Which part of your body temple do you love the most?.*

What is your favorite mantra/positive affirmation?*

What are you currently struggling with in your life? *

Have you practiced the mirror work ritual before? Do you like homework?*

Are you currently experiencing significant life changes and seeking guidance and tools for personal growth?*

What is your biggest accomplishments in life?*

What is your biggest failure in life/what lessons are learning from it?*

Reflection: What has been the hardest thing you have had to overcome in life, and what did you learn from this experience? *

In the past year, what were your top 3 blocks or disappointments? (e.g., procrastination, poor habits, limiting beliefs, fear of success, imposter syndrome, etc.). Please be as specific as possible. *

What are the 3 constant inner critics or self-negative thoughts/phrases that you often hear and feel stuck with?*

How do you typically deal with challenging emotions, people, and situations, both at your best and at your worst?*

What do you perceive is missing in your ability to evolve in your life, both internally (mindset, emotions, etc.) and externally (resources, tools, etc.).*

How do you tend to deal with challenging emotions, people, and situations, both at your best and at your worse? *

What are your core values?*

What are your dealbreakers?*

Why do you believe that I am the ideal guide/facilitator who can lead you on this transformative journey?*

What would make working together a game-changing experience for you? And what will you do to ensure you make this happen—no matter what?*

What are your top weaknesses related to the life you’re creating? *

What skills and strengths will you be bringing to the retreat/program/ceremony?*

What is your 3 favorite songs?*

What is the best compliment you ever received? *

When I ask 2 of your best friends who is kellie? Why is she your best friend? *

What is Kellie giving in your life that no other does? asking to your best friends *

My younger self Kellie, around 10 years old what was she like, what was her dreams?*

What do you admire in yourself? *

What is usually the last thing to do you do at night before bed?*

In a nutshell, how would you describe your unique genius? (The thing you’re known for that others are Wow’ed by.) *

What is your biggest fear?*

When was your last relationship, how long did it last, where was it why aren't you together?*

When you swear, which words are you saying?*

How comfortable are you with speaking your naked, vulnerable truth and expressing your authentic self?*

Are you open to exploring spirituality and self-discovery practices, even when they might be outside your comfort zone? *

How do you envision your personal spiritual journey unfolding?*

Are you open to surrounding yourself with positive, supportive, accountable, and high-vibe people?*

Are you ready to align with your purpose, tap into your inner wisdom, and create a life of joy and fulfillment?*

Are you courageous enough to face your fears and rise like a phoenix, reborn and empowered?*

Finish the sentence: Practice makes ...*

What has been your biggest breakthroughs from June to Now?*

Do you agree and confirm that all parts of my Recreate Your Reality/ Self-love Magic Mirror retreat is private and no part of it will be copied for your clients, retreats, programs, ebook, pdf's, audios? *

Are you ready to invest in yourself?*

My 1:1 in private retreat includes the progress of iconic essence photography, do you agree with it? for you and social media*

My very profound, transformational 1:1 in private retreat is between 4 to 7 days & investment starts from US 6000, is your heart calling it? includes accommodation/private bedroom ensuite bathroom, 3 meals a day, 1 massage, creation of your own journal, homework daily during the retreat, rituals, 30 minutes of zoom call prior your arrival & bonus surprises*

Is there anything else you want to tell me or would like me to know apart from our last Zoom session ;-) ?*

Please upload a photo of yourself (jpeg/jpg format only)

Browse Files

SUGGESTIONS

Water: Drink provided

Photoshooting: Glam, Colorful, Sexy, lingerie, extravagant, Wild and Raw, sensual, comfortable yoga clothing, jewelry, accessories.

Altar: Bring your favorite statues, stones, etc ...

Snacks: Bring your favorite healthy snacks & drinks

Supplements: Bring your own supplements

Food: included

Magazines: Bring all kinds of categories of magazines with you

Swimming suit: Bring your bikini

Mosquito repellent, sunscreen

Bring what you think is also important for me to see during your journey

GUIDELINES

By checking each box, you agree to each guideline:

No alcohol or substances during the sessionNo smoking during the sessionNo cell phone during the session, no texting, no calls, no videos recording, no audio recordings & no images taken during the session.No profanitiesNo leaving the premises during the retreat

Agreement

To ensure a smooth and respectful experience, please take note of the following guidelines for our private session/retreat/ceremony:

This is a private session/retreat/ceremony designed exclusively for you.

Confidentiality is of utmost importance, and we kindly request that you refrain from sharing any information or experiences outside of our shared container.

Mutual respect and understanding are key to creating a positive and nurturing environment. We appreciate your commitment to treating each other with kindness and respect throughout our time together.

Emotions are a natural part of the process, and we acknowledge that they may arise during and after the session/retreat/ceremony. We are here to support you in navigating and processing these emotions in a compassionate manner.

Feel free to ask any questions and seek guidance as needed. We are here to provide assistance and support throughout your journey.

It is important to avoid taking any words or sentences out of context and discussing them with friends, family, or others. Respecting the privacy and integrity of our work is essential.

We both have each other's best interests in mind and are committed to your personal growth journey. Your progress and well-being are my top priorities.

Please note that once the session/retreat/ceremony is booked, no cancellations or refunds are permitted. We appreciate your understanding in this matter.

Thank you for your cooperation and commitment to creating a meaningful and transformative experience together.

I look forward to embarking on this journey of self-discovery and self-love with you.

Thank you, from my heart to yours,
Emmanuelle Blanc

I understand and agree to this agreement form.*

Clicking on this box is synonymous with signing this legally binding document.

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