Unity of Heart Immersions
The journey of Self Discovery through the Practice of Self Love
Name
First Name
Last Name
Email
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Address
Street Address
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City
State / Province
Postal / Zip Code
Phone Number
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Emergency Contact
Are you happy to be added to a telegram group before retreat so we can share info about zoom calls, travel etc?
Where do you think you’ll be travelling from (for lift shares and link-ups)?
Health and Wellbeing
Some medications and health problems are contraindicated and it's important we make sure it is safe for you to participate, so please share as much information as you can.
Do you have any dietary requirements we should know about?
Do you have any allergies to specific foods? If yes, please specify which foods and the reaction that results when you ingest the food
Please describe your experience with fasting
Do you have issues with low blood sugar?
Do you suffer from Fainting or Low Blood Pressure?
Have you ever undergone major surgery (requiring a general anesthetic)?
Do you have any physical injuries, mobility limitations ? If so, please provide details of the injury/surgery including the ailment, date of operation and any limitations that you are now bound by.
How would you describe your current state of health? Please be as detailed as possible
Is there anything that might support you in being more comfortable during the retreat?
Are you currently pregnant?
Are you currently receiving therapy or attending any kind of support group? If yes, please describe in detail, and the approach of therapy you have been involved in.
Have you ever experienced addiction to any substances either in the past or present? If so can please tell us more about your experience.
Are you currently taking or have you recently stopped taking any medication? If yes, please specify which medication(s)
Is there anything else you'd like to share about your health or wellbeing?
Immersion Dieta
Have you had experience with this type of work before? If yes, please provide details
Have you experienced adverse or particularly difficult experiences with this work that you have found hard to integrate? If yes, please provide details.
Is there anything that you think might come up as a result of this work?
Please share your intention for wanting to participate in our sacred retreat. If you have not done so, please take some time to reflect deeply on this question. It is very important for us (and you) to clarify what you hope to achieve by attending our retreat both for your own healing and for us to determine the specifics of your immersion.
Please describe your current living and work situation; if you are studying or working, your profession and describe the home environment that you will be returning to after your time with us. This information is important so as we can do our best to prepare you for returning to your home life after your sacred journey with us.
Is there anything else you'd like to share?
I declare that I have answered all of the above questions fully and honestly and I have not withheld any information that I believe could be important....
Date
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