Be sure to fill out this registration form after you have made a deposit and you'll be all set.
Contact: @christine.heyloa@gmail.com
Name
*
First Name
Last Name
Email
*
example@example.com
Age
Height
*
Weight
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What name do you like to go by?
On a scale of 1-10 rate your overall physical health 10 being excellent.
*
On a scale of 1-10 rate collectively the relationships in your life 10 being satisfying.
*
On a scale of 1-10 rate your anxiety with 10 being high.
*
Check your top three health concerns:
*
Aging more slowly
Managing my weight
Energy balance
Self Healing
Reducing Anxiety
Do you smoke?
*
Yes
No
How do you often drink?
*
Occasionally
Random
Never
Do you practice yoga?
*
Yes, Of course
Sometimes
Not at all
Can you walk a mile without stopping?
*
Yes
No
Do you meditate?
*
Yes, Of course
Sometimes
Not at all
Are you interested in sharing a room for a reduced room rate?
*
Yes
No
Are you taking mood-altering prescription meds?
*
Yes
No
If Yes, describe
Submit
Should be Empty: