SOUL JOURNEY RETREAT IN COSTA RICA APPLICATION FORM
First Name
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Last Name
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Email
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example@example.com
Phone
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who referred you?
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Emergency Contact Name and Phone number/email.
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Please describe your current journey in both personal growth and any professional endeavors.
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What are the main challenges or obstacles you are facing in your personal and professional life?
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How are these challenges affecting your overall well-being, relationships, and/or professional satisfaction?
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Describe the 'nudge' or 'pull' you're feeling towards making a change or seeking something more in your life.
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Why do you believe now is the right time for you to embrace a deeper or more expansive version of yourself?
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Do you have any medical conditions we should be aware of?
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Please list out all diagnoses and medications (past and current)
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What is your experience with plant medicine (experience is not required for this)
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Is there anything additional you'd like us to know?
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Your Signature
*
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