Your name Your email Your Phone What are your goals for this retreat? Lose weightImprove fitnessCalm the mindTime aloneMeet like-minded peoplePersonal healingLearn more about natural healthOther (please specify) Have you been diagnosed with any of the following? Diabetes type 1Diabetes type 2ObesityHigh blood pressureCancerIBS or other digestive symptomsArthritisAcid refluxOther (please specify) Do you take medication for any of the following? Diabetes type 1Diabetes type 2ObesityHigh blood pressureCancerIBS or other digestive symptomsArthritisAcid refluxOther (please specify) Do you experience any of the following? Lack of sleepAnxietyStressIrritabilityBurn outOther (please specify) Are you addicted to any of the following? CoffeeAlcoholSugarRecreational drugsOther (please specify) Which of the following activities interest you? YogaMeditationPersonal trainingMassageHolistic healing eg. Reiki & sound healingDanceOther (please specify) How long do you wish to join us for: 3 days7 days14 days21 daysOther (please specify) How many people in your group? Just meWith partner or friend3 or more (please specify) Sign me up for the newsletter!
