Retreat Application Form

Retreat Application Form

Wild & Rooted: A Sacred Feminine Retreat
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
E-mail*
example@example.com
Phone Number*
Emergency contact*

First NameLast Name
Emergency contact phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Health Details

In order for us to best serve each participant on the retreat, please answer the following questions. All answers will be kept strictly confidential.

Please respond to these health related questions*

Rows	Yes	No
Do you have any chronic physical conditions or recent surgeries we should be aware of?
Do you have any or have you had any physical health problems (e.g. diabetes, seizure disorders, high blood pressure, cardiovascular conditions, etc.)?
Do you have a history of mental health diagnosis or current concerns (e.g., depression, anxiety, PTSD, bipolar disorder, schizophrenia, etc.)
Are you currently taking any medication? (please list all medications, prescribed or over the counter, especially psychiatric or mood-related)
Are you currently pregnant or trying to become pregnant?

If you answered "Yes" to any of the questions above, please provide details below
YesNo
If you answered "Yes", please briefly share what you've worked with, how often, and what those experiences were like:
YesNo
YesNo
What calls you to the Wild & Rooted Sacred Feminine Retreat at this time in your life, and what are you most hoping to receive from this experience?*
What are your current practices, if any, for integration, grounding, or self-care?
Do you have any dietary requirements/allergies/preferences?*
Is there anything else you'd like us to know or that feels important to share?
Thank you!

Thank you for your application. We will review your responses with care and be in touch soon to schedule a brief connection call to ensure alignment and answer any questions.

With love,

Stephanie and Willow
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