SOTFW Application form

SPIRIT OF TANTRA FOR WOMEN application form

We understand the potential sensitivity facing some of the questions below. This information is valuable to us for knowing and understanding you better which enables us to determine if this program is suitable for you. We strive to offer the most appropriate and best possible care to support you. Please answer honestly. These questions and answers are strictly confidential and will be reviewed by the retreat facilitator and team only. Thank you so much!
Name*

First NameLast Name
Preferred Name (if relevant)
Gender*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
How Did You Hear About Us?*
Name of friend?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your relationship status?*

MarriedSingleDivorcedWidowedOther
Do you have children?*

YesNo
Please take a photo of yourself (photo will automatically save once it is taken)*
application Questions

Please describe in detail to the best of your ability the following questions..
Have you done any previous personal development retreats / workshops?*

YesNo
Please list the retreats you have done and how long ago?
Please describe your relationship with your family, both present and childhood. *
What early childhood event/s made you feel unsafe and/or impacted your life? *
Please describe in detail to the best of your ability.
Have you ever been subject to any physical, psychological, emotional or sexual abuse? (if yes, please let us know what happened and when it happened)*
Please describe in detail to the best of your ability.
Please describe how you deal with conflict today when uncomfortable conversations and/or feelings arise? *
Is there anything that you feel is limiting you in your life today. *
Please describe in detail to the best of your ability.
What are you hoping to get out of the retreat? *
What are the primary resources that support you in your life today? (nature, movement, friends, family, animals, music, etc..) *
Please describe in detail to the best of your ability.
Medical Questions

These medical questions are an important part of your personal development journey with us, and will serve as a guide to better support you.
Are you currently seeing a counsellor, psychiatrist, or psychologist?*

YesNo
Could you please let us know why you are seeing a counsellor/ psychiatrist/psychologist?
Are you now being treated or have you ever been treated (includes medication and hospitalisation) for any mental health conditions, such as (but not limited to): PTSD, psychosis, chronic anxiety, paranoia, schizophrenia, bi-polar disorder, clinical depression, sleeping disorders, etc..?*

YesNo
Please provide in-depth details to your condition, the practitioners diagnosis, the medication prescribed (if any) and/or if you were hospitalised (if so, for how long):
Have you ever thought of harming yourself or trying to take your own life?*

YesNo
Please let us know when was the last time you self harmed and/or considered taking your own life?
Are you currently taking or have been prescribed psychiatric medications?*

YesNo
Please share which prescriptions, for what diagnosis, for how long and the side effects if any.
Have you ever been a patient in a mental health care facility?*

YesNo
Please state when and for how long?
Have you ever been diagnosed with any type of personality disorder?*

YesNo
Please state the diagnosis.
Have you ever suffered from, or currently experience panic attacks?*

YesNo
Please specify when you had your last panic attack?
Are you currently under the care of a medical doctor?*

YesNo
Please state for what reasons and for how long?
Have you ever struggled with addictions of any kind (sex, drugs, alcohol, gambling, work, etc..)?*

YesNo
Please specify when and for how long.
Do you have any allergies?*

YesNo
Please list them.
On average, how many hours do you sleep?*
Do you feel well rested when you wake up?*

YesNoNot sure
Please indicate if you have any disabilities, disorders or health conditions that may affect your participation.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Final Questions and CommentS
Is there any additional information that you feel we will benefit from knowing to support you on your journey?
Do you know anyone attending or facilitating Spirit of Tantra for Women?*

YesNo
Please state their name(s) and their relationship to you.
Do you have any specific accommodation requirements? If yes, please indicate.
While we strive to accommodate everyone's needs, please understand that it may not be feasible in every case due to venue limitations. Your understanding and cooperation are greatly appreciated.
During the retreat, we will be using different tools, such as active meditations, emotional release work and trauma release work. It is of utmost importance you understand that this retreat addresses strong topics related to old wounds. It is our duty of care to inform you even though you will be supported every step of the way.

Yes, I understand!Yes, I understand and would like to discuss further during In-take Call
Please note, your acceptance to Spirit of Tantra for Women is only confirmed once we have had the chance to review your application form. Rupda.com reserve the right to decline acceptance of any potential participant into the retreat for the safety and well-being of all involved. (in this case a full refund is processed)*

I understand and agree to this term
On signing this form you agree that the information provided is accurate and complete to the best of your knowledge, and that you consent to the processing of your personal data in accordance with our privacy policy. You also agree that if anything changes related to the above questions in this form, that you are oblidged to let us know before attending the retreat via email: info@rupda.com

Your data will be held with strict confidentiality. We do not share any of your data.
Please add your Legal Signature*

Clear
On signing this form you agree that the information provided is accurate and complete to the best of your knowledge, and that you consent to the processing of your personal data in accordance with our privacy policy.
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SPIRIT OF TANTRA FOR WOMEN application form

application Questions

Medical Questions

Final Questions and CommentS