Please complete this form to participate in our Rewilding Tantra Retreat.

All your information remains confidential

Full name

Date of birth

Facebook profile link

Gender

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Female

Other

Address

Street Address

City

Postal /Zipcode

Apartment,Suite,bldg

State /Province /Region

Country

Your Phone

Your Email

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 give a summary of your experience in meditation, counselling, self development or other workshops you have attended prior.

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.

Please Describe

What are your reasons for coming to this workshop? What are you hoping to discover, learn or achieve in this workshop? What would be your most wanted shift?

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:

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

I agree

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