REVIVE Registration

Name*

First NameLast Name

Email*

example@example.com

Mobile/ WhatsApp Number*

Country / Time Zone*

Street Address

Street Address Line 2

Country

What drew you to this program? What are you hoping to experience or shift?*

Briefly describe your current work/life/family circumstances. Are you feeling energized by it, drained by it, or somewhere in between?*

Where you are in your healing journey right now? Is there anything about your physical, emotional or psychological health and wellbeing that would be helpful for me to know so I can best support you in this container?*

Are you currently working with a therapist or other healing practitioner? If yes, please describe briefly.*

Have you worked with somatic practices before?*

YesNoNot Sure

Have you participated in Shamanic Breathwork before?*

YesNoNot Sure

Any additional comments or information you would like to share?

How did you learn about REVIVE?*

This is a small, intimate circle. What is shared in the group, both during live sessions and in the WhatsApp community, is held in confidence. By joining, you agree to respect the privacy of others, maintain confidentiality and not disclose personal experiences shared by other participants.

Payments are refundable or transferrable up to 30 days before the start date. Cancellations 29 days or less result in forfeiture of all payments. This is to ensure your commitment and full participation. Payments will be fully refunded if the program is cancelled by me for any reason. If you cannot attend a session, you will receive the recordings of teachings and practices, though personal sharing is never recorded.

I have read and agree to the confidentiality and cancellation terms above.

Signature*

REVIVE: A 5 Week Journey Back to Self

Agreement