HEART HOWL Retreat Application

HEART HOWL

Retreat application
Name*

First NameLast Name
Email*
example@example.com
GDPR compliance*

Please tick this box to consent to receiving emails about your application to HEART HOWL retreat
Date of birth*

MonthDayYear
Date
Phone Number incl. country code*

Country CodeArea CodePhone Number
Emergency contact*

First NameLast Name
Emergency contact phone number*

Country CodeArea CodePhone Number
Where do you currently live?*

CityState / Province

Postal / Zip CodeCountry
What is your biological sex?*

FemaleMaleOther
Please upload a photo of yourself*

This helps us remember your name and details and allows us to better support you during the retreat.
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How did you hear about this retreat?*
What is your intention and desire for joining this retreat? *
Insofar as you didn't already address this in the previous question, please tell me a little about where you are at in your own personal journey. What are the big questions and topics that are alive for you? What do you feel life is asking of you to learn and embody at this stage in your life?*
How fulfilled are you in your life currently? Do you feel fulfilled in your friendships, in your romantic and erotic life, in your purpose and creative expression, in your relationship with Life as a whole?
Please tell me about any significant life events that have shaped you. *
Do you have any experience of personal and our spiritual development approaches and retreats, therapy, embodiment practices, etc. ?*
Please tell me about any past and/or present mental health conditions or behavioural problems. And have you ever experienced major trauma that you are aware of (e.g., physical, emotional, verbal or sexual abuse, or other types of trauma)? Please give details of how you worked through these experiences and how, if at all, they affect your life at present.*
Are you currently taking any medication that treats a condition of the brain or addresses a psychological or psychiatric problem? If so, please give details of the type of medication, your dosage and the condition that is being treated.*
Are you currently experiencing any of the following? (highlight all that apply)*

Feeling intensely emotionally overwhelmed, unable to cope and maintain daily functionsUnpredictable and extreme mood swings, including anger outbursts, intense anxiety, or uncharacteristic excitementSuicidal thoughts or impulses to self-harmSymptoms of psychosis such as paranoia, delusions, hallucinations or intrusive voicesAnger management issuesDepressionGeneral anxietyPanic attacksSocial anxietyPhobiasPTSDOCDADHDEating disordersSubstance Use disordersPersonality disordersDissociative disordersSleep disordersNone of the aboveOther
Do you have any known triggers that may cause you to become highly distressed, and if so, what are they?*
Are there any regular activities that you find beneficial to your mental, physical or spiritual well-being and which you use to manage difficulties? This could include meditation, yoga, time spent in nature, creative practice, or any other practices that support your personal growth, self-expression and capacity to resource yourself.*
Please describe your general physical health. Are you living with any medical conditions?*
Are you using any medications or supplements? If yes, please provide the name of your medication, dosage, frequency of use, as well as details of the condition being treated.*
Please share about your past and present use of psychoactive substances, this could incl. recreational drugs such as cocaine or speed, psychedelics, or legal substances such as alcohol, caffeine, sugar, nicotine, or codeine.*
The event may involve physical movement, deep emotional work, physical connection with others, and nature exploration. All activities are optional so you will always have the choice whether to participate in any given activity or not. Having said that, from your current standpoint, do you foresee any problems participating in these activities?*

YesNoMaybe
If yes or maybe, please specify:
Do you have any allergies or specific dietary requirements? If yes, please let me know a bit more about your condition or allergies and any specific needs you may have.*
Do you have a room preference?*

Same sex shared room (2-3 people)Private single roomOther
Is there anything you feel I should know about you that has not been asked about previously?*
I have provided full and honest responses in this questionnaire, and will inform Stefana Bosse in good time of any relevant changes before participating in the retreat - including new diagnoses, medications or major life events. I understand that by withholding, downplaying or falsifying information, I could put myself at risk of harm. I understand that a relationship of openness and good faith with the facilitator creates the best possible foundation for a deep and valuable experience.

I agreeI disagree
Please schedule your 15-minute intake call before pressing "Submit" on this form.

This call will be an opportunity for us to meet and get a feel for each other, for you to ask any questions you may have and for us to explore whether this retreat is the right next step for you on your journey.

I look forward to meeting you!
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