Blue Lotus Wellness Immersion Application

Why would you like to attend a Blue Lotus Infused Wellness Immersion Retreat?* This field is required.select your TOP 5 priorities

I want to relax and take some time out

I need to put myself and my needs first

I want to spend a weekend with likeminded women

I'm interested in discovering new selfcare tools and techniques

I'm interested in learning more about integrating essential oils to improve wellness

I need to learn how to improve my stress management capabilities

I need to learn to improve energy levels and resilience

I need to discover ways to get more restful and restorative sleep

I want to learn to create inner peace and calm and release what no longer serves me

I want to learn techniques to restore balance and harmony

I simply need a break!

Where will you be traveling from?* This field is required.City / State

Which Infused Wellness Immersion Retreat are you interested in?* This field is required.

February 16-18, 2024

additional options in 2024

What are you hoping to get out of this retreat?* This field is required.We'd love to hear it in your own words.

What is your greatest challenge at the moment?* This field is required.So we can ensure this retreat will truly benefit you.

What questions do you need answered before you can commit to this wellness experience?* This field is required.Please let us know so we can give you more detailed information.

What do you consider your greatest strength?* This field is required.

What do you consider your greatest challenge?* This field is required.

What are you passionate about?* This field is required.

What is your level of experience with essential oils?* This field is required.

I am a beginner / new to essential oils

I have used them but just for their amazing scent

I have used them to support physical and emotional wellbeing

I am very experienced using essential oils

Have you had previous experiences with any of the following?* This field is required.click all that you've had experiences with

mediation

journaling

mindfulness

restorative yoga

soundbath

forest bathing

making pampering face masks

making pampering foot soaks

Aromatouch Technique (ATT)

Infrared Light Therapy

biofeedback for relaxation

creating custom essential oil blends

supporting sleep with essential oils

What is your name?* This field is required.

First Name

Last Name

How old are you?* This field is required.For the greatest benefits of participants we try to group women of similar age ranges and wellness needs.

I understand that Blue Lotus Infused Wellness Immersions are Women ONLY retreats.* This field is required.

YESNO

Please upload a photo of yourself. Any recent pic will do.* This field is required.

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Thank you for all your answers. Just a few more questions: Will you be attending by yourself, with a friend or a group of friends?* This field is required.

by myself

with several friends

with a friend

If no single beds are available, are you open to sharing a King or Queen sized bed with a weekend retreat sister?* This field is required.

YESNO

Do you have any food allergies, Intolerances, or dietary requirements we should be aware of?* This field is required.

Do you have any skin sensitivities or skin issues we should be aware of?* This field is required.

Do you have any physical health challenges or concerns?* This field is required.

Are you currently or have you in the past suffered from any mental health challenges? e.g PTSD, depression, eating disorders, OCD, panic attacks/night terrors, bipolar, schizophrenia etc. If yes please give details?* This field is required.Disclaimer: We do not judge and ensure that this information is kept confidential. We ask in order to understand personal healing requirements.

Do you have any phobias?* This field is required.

Do you experience sleep walking, snoring, insomnia or any other sleep disturbances? If so, please provide details.* This field is required.

Do you have any past or present addictions?* This field is required.Disclaimer: We do not judge and ensure that this information is kept confidential. We ask in order to understand personal healing requirements.

Do you have any questions?* This field is required.

What is your Email address?* This field is required.We will contact you via email regarding the status of your application.

example@example.com

What is your Cell Phone Number* This field is required.We will send you a quick text message once the email has been sent because we don't want you to miss any important information.

Area Code

Phone Number