Bali Empress Retreat 2023 Consideration Form

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Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
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What is your date of birth?* This field is required.
4
Where are you currently located?* This field is required.City, state, Country
5
Do you identify yourself as a female entrepreneur? * This field is required.
YESNO
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What prompted you to want to join us?
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What does infinite abundance mean to you in 3 words? * This field is required.
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What’s your intention for 2023 in one word? * This field is required.
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What are you planning to walk away with from this experience?* This field is required.
10
Your intention for this retreat* This field is required.
Uplevel abundance in all areas of life
Chill, relax, hangout
Release and let go old patterns and beliefs
Mind, body, soul rejuvenation
Shift levels of consciousness
Learn new skills and tools
Connect with other like minded visionaries
11
Tell us 1 fun fact about you 👇🏽* This field is required.
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Tell us 1 of your unforgettable travel moment?* This field is required.
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What’s your experience with Breathwork?* This field is required.
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If you haven't had a breathwork experience before, are you open to new experiences & energy work?* This field is required.
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What current self care habits do you practice?* This field is required.
Breathwork
Meditation
Guided practices/mindfulness
Journaling
Exercise
Music
Sound healing
Reiki
Praying
Other
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What are your current beliefs about wealth?* This field is required.
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Have you ever been treated for depression, trauma, anxiety? * This field is required.The intention of this question is not to judge you but to ensure not to further injure or harm you.
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Have you endured any trauma in your life that you are aware of? * This field is required.The intention of this question is not to judge you but to ensure not to further injure or harm you.
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Do you have any current psychiatric diagnosis that you are aware of? * This field is required.The intention of this question is to ensure you are a good fit for the deep subconscious work.
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Are you currently on any psychiatric medication? * This field is required.The intention of this question is not to judge you but to ensure not to further injure or harm you.
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Would you be open to joining us on a quick 30 mins zoom call with me to finalize your selection? * This field is required.
YES - Please send me the linkNO
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This elite retreat is a 4 figure investment for 5 nights/6 days in Bali, do you align with releasing that level of abundance so you can cultivate the energy to receive more abundance in 2023?* This field is required.Includes: Accommodation for 6 days, Breakfast & Dinner, activities, (ex: exploring Balinese culture & Bali, 1 massage, breathwork, yoga), Masterclasses/workshops/ceremonies/sound healing/energy work & much more included.
YESNO
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This retreat isn’t for you if you are not willing to attend Breathwork workshops/ceremonies/masterclasses. * This field is required.This is a 6 Days/ 5 nights commitment, there will be down time every afternoon.
Ok, can’t wait for itYikes
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Please share with us your picture so we can put a face to your name 😃
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You have a valid travel/health insurance for this trip? If not you plan to get one before the trip begins and send us a copy?* This field is required.
YESNO
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