Confidential Retreat Registration

Name*

First NameLast Name

What is the first name or nickname you would like to be called?*

What are your preferred pronouns? (ie, she/her or they/them

E-mail*

Where do you live?*

Street Address

Street Address Line 2

CityState / Province

Country

Phone Number*

Area CodePhone Number

Relationship Status*

Occupation*

Birthdate*

MonthDayYear

Emergency Contact Name*

First NameLast Name

Emergency Contact relationship to you*

Emergency Contact Phone (cell preferred)*

Area CodePhone Number

How did you hear about this retreat?*

If other, please specify.

Please indicate your level of familiarity with the chakra system. *

	1	2	3	4	5	6	7	8	9	10

1 is Not at all familiar, 10 is An expert

What is your level of experience with sacred sexual healing work (workshops, trainings, and/or private sessions)?*

	1	2	3	4	5	6	7	8	9	10

1 is No experience, 10 is Lots of experience

What do you hope to receive from this workshop?*

Are you willing to show up and simply receive rather than coming as a "healer," "helper," "teacher," or "giver"?*

What are your passions, dreams, and deepest desires in life?*

Do you have any health issues that would affect your participating in the workshop? (please describe so we can best support you)*

Do you have any history of mental health issues, mental illness, or suicidal tendencies? Have you been diagnosed with any mental imbalances? (please describe including any diagnoses)

Do you have (or suspect you have) a history of sexual, emotional, physical, or religious trauma?*

Do you have any special needs/allergies around food? If so, please specify. We will do our best to accommodate your needs. *

Anything else you would like to share with us, or that it would be helpful for us to know?

By submitting this form, I agree to attend the workshop as a participant rather than a healer/helper/giver. I understand that the workshop I will be participating in is provided for the purpose of healing, releasing, awakening, and reclaiming wholeness.

I further understand that the workshop should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that the facilitators are not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the workshop should be construed as such. I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the facilitators updated as to any changes in my profile and understand that there shall be no liability on the part of the facilitators for any reason whatsoever.