BALI - Wild Woman Retreat

You're one step closer to paradise! Please take the time to complete the intake form so that you may be contacted to confirm interest in the retreat and proceed with payment options. Looking forward to connecting with you!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Social Media
(Optional: LinkedIn/ Instagram / Facebook/Website )
How did you learn about this Wellness Vacation?*

Deni SanxhakuFacebook / InstagramWellness Vacay RetreatsChandra AieshaOther
What's inspiring you to take a Wellness Vacay? What do you wish to receive from this Wellness experience?*
Dietary*

No RestrictionsGluten-FreePlant Based / VeganOther
Will this be your first out of country experience?

YesNo
Do you need assistance coordinating a flight that aligns?*

YesNoOther
Will this be your first retreat?

YesNo
Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma,diabetes, seizures, osteoporosis,difficulty walking, mental health concerns, etc.)*
What is your experience with Yoga, and/or Meditation?*
Are you bothered by scents (essential oils, incense, perfumes etc.)? If yes, please let us know the details.*
What is your level of comfort when it comes to getting into the water? (pool/ocean/lagoon/river/waterfall)*
Room Booking Style Interested in:*

$2600 - Shared Room$3200 - Private Bedroom$5000 - 2 Friends sharing a room ($2500/each)
How would you like to invest in your Wellness Retreat Experience?

Pay in FullAffirm - Credit Financing OptionHold space with $500 Deposit and make paymentsHold Space for $200 (applying $300 off early bird rate (exp 6/30)
Is there anything additional that you would like to share about yourself?
OPTIONAL
Vibe Check | Phone Call
Check your email for all future updates.
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