Retreat Intake Form

First name

Last name

Phone

Emergency Contact Name & Number

Who or what are you grieving?

When did this loss occur?

How would you describe where you are in your grief process?

Have you attended therapy, support groups, or previous retreats related to your grief? Please share about your experience.

What drew you to this grief retreat?

What are your intentions for your healing journey beyond the retreat?

What are you hoping to receive or experience during the retreat?

Are you currently under the care of a therapist or counselor? If yes, are they supportive of your attending this retreat?

Do you have any mental health diagnoses or current mental health concerns we should be aware of? (Your response will remain confidential and is only to help support your wellbeing.)

Do you have any physical limitations, dietary restrictions, or allergies?

Are you planning to sign up for an IADC session?

Yes

Undecided

Are you planning to sign up for a Human Design session? If so, please provide birth information including location, time, and date.

Are you interested in the Mindful Microdose Guideship option? If so, when would you like to begin this piece? (At least 4-6 weeks ahead of time is suggested, but more time is even better)

Please share any additional information you would like us to know.

Please tell us a little about your sleep and wake schedule so we can ensure you are matched up appropriately.

Do you have any concerns or questions that would be helpful to discuss ahead of the retreat?

Do you have any injuries or special considerations I should be aware of to help make your yoga practice more comfortable?