Shadow Work Retreat Participant Form
November 20, 7:30 pm, Embody Healing, LLC, 1824 Murray Ave. Ste. 305
Full Name
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First Name
Last Name
Email Address
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Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Herbal teas and essential oils will be present in the space. Please list any relevant allergies you may have, or write none or not applicable if this isn't relevant:
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A folding chair will be provided for the event. Is there anything else you need in the space, any other accommodations necessary to enable you to attend?
This retreat is NOT appropriate for those with active, severe trauma without support, those who are actively suicidal, or for those currently experiencing psychosis. This retreat is for personal enrichment and growth, and is not medical or mental health care. Shadow work can bring up intense emotions, discomfort, or past trauma. If you feel overwhelmed, destabilized, or unsafe at any point, please pause the practice and reach out for supportive services. Shadow work never justifies harm to yourself or to another. Embody Healing, LLC and David Gamble-Moore, M. Div., HP, Clinical EFT Practitioner, Herbalist can not accept liability for effects of the space or content of the workshop.
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I understand and accept responsibility for my mental/emotional state and physical safety. I hereby release, waive, and forever discharge Embody Healing, LLC and David Gamble-Moore, M.Div., HP, Clinical EFT Practitioner, Herbalist from any and all liability, claims, demands, or causes of action arising out of negligence or any physical injury, illness, or damage I may sustain as a result of my participation in the workshop or use of herbal supports provided. I agree to indemnify and hold harmless the practitioner and company against any and all legal fees or costs resulting from claims brought by me or in my behalf.
Our rain date/ reschedule date is Nov. 27, 28, 29. We do not provide refunds for announced rain dates.
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I understand and agree
What are your intentions or expectations for this retreat? Anything else you want us to know? This question is not necessary to answer, but it helps me serve you better!
How did you hear about our workshop?
Friend or Family
Ad in the mail
Bookmark in a little free library
Newsletter
Facebook event page
Referral from a mental health or medical professional
Thank you! See you there.
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