Rooted & Restored™ 🌸🌹✨

Rooted & Restored™

Register for the Sedona experience and secure your spot with a deposit.
Personal Information
Full Name

First NameLast Name
Email Address
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Address

Street Address

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Mobile Phone Number
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How did you hear about us
Emergency Contact Full Name

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Emergency Contact Phone
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Retreat Agreement and Waivers
Cancellation Policy — $350 deposit non-refundable. Registration closes August 15 2026. Cancellations 60 plus days before October 16 get full refund beyond deposit. Cancellations 30 to 59 days get 50 percent refund. Within 30 days no refund. Spot transfers allowed until September 16 2026 with $50 fee.
Liability Waiver — Participation involves outdoor walks group coaching and wellness activities. This is a coaching experience not a clinical program. Dr. Kelly Jackson is facilitator not treating clinician. Participant releases Dr. Kelly Jackson and Changing Tides Counseling and Behavioral Health LLC from all claims.
Confidentiality Agreement — All disclosures stay confidential. What is shared in the retreat stays in the retreat. Dr. Kelly may remove disruptive participants without refund.
Payment Agreement — Early Bird shared $1,850, Early Bird private $2,350, Regular shared $2,000, Regular private $2,500. Deposit $350 via Venmo to @DR_KJackson. Four payments due July 1 August 1 September 1 October 1 2026.
I have read and agree to all retreat terms, waivers, and policies listed above. I understand this is my legally binding agreement.
Photo Release
Signature
Date of signature

MonthDayYear
Date
Roommate and Retreat Preferences
Most rooms are shared. Private room upgrades limited to 2 rooms are not guaranteed.
Room preference
Sleep considerations
Roommate request
Health and Wellness Disclosure
This information is strictly confidential. This retreat is a coaching experience not a clinical program.
Food allergies
Dietary Needs (if any)
Allergy severity
Dietary preferences
Physical health conditions
Currently working with a therapist
Emotional wellness notes
Retreat intention
T-shirt size
Travel method
Estimated arrival time October 16
Should be Empty:

Rooted & Restored™

Personal Information

Retreat Agreement and Waivers

Roommate and Retreat Preferences

Health and Wellness Disclosure