Couples Retreat Registration Form

All your information remains confidential

Full name

Partners Name

Date of birth

Partners Email Address

Partners Phone Number

Facebook profile link

Instagram profile link

Gender

Male

Female

Address

Street Address

City

Postal /Zipcode

Apartment,Suite,bldg

State /Province /Region

Country

Your Phone

Your Email

How long have you been in relationship with your partner

Profession

Emergency contact person name

Emergency contact person phone

How did you hear about this workshop?

Facebook

Instagram

Friend

Email

Other

Please elaborate

Personal Info

The information requested below is very important. It will help the Group Facilitator(s) to work with you more effectively. The information will only be seen by the Group Facilitator(s) and the Group Organiser.

Self Development

Please describe any self development work you have done

Tantra

Have you had any previous experience of Tantra or relational workshops? If the answer to this question is “Yes” please outline this experience briefly.

History

Please describe significant events from your family environment, your upbringing and other difficulties you have experienced in your childhood and adult life that you feel may be relevant for your process.

Physicality

The group includes some physically active structures (some meditations and exercises and dancing). Please let us know if this will present any physical difficulties for you:

Health

Please tell us about any health issues and/or infectious diseases you may have. Please also tell us if you are on medication of any kind (please specify).:

Mental Health

Please indicate below if you have any history of psychiatric treatments or if you are currently taking any psychiatric medication:

1. Why did you sign up for this Couple’s Retreat?

2. What are you hoping to get out of it?

3. What are areas that you want to improve on in your relationship?

4. What are areas that you feel that you are really good at with your partner?

5. Do you feel you are able to be heard in your relationship?

6. Are you able to be totally transparent?

7. What do you feel is most lacking in your relationship (that is not a bad thing, only then can we work on it and make changes)

8. How would ideally your relationship have transformed after doing the couples retreat

9. Is there anything in your sex life or intimacy that you would like to experience less or more of?

Is there anything else you would like to add?

I have read and agreed to the Waiver and disclaimer and the Cancelation Policy

I agree

I don't agree