Awakening Retreat Intake Form

Step 1:

Complete the Retreat Registration Intake Form. It's imperative that all fields include the appropriate information.

Step 2:

Payment is REQUIRED to submit this form. Responses are not saved unless the payment has been processed.

Step 3:

Once approved by our Team, you will receive a Welcome email / WhatsApp with information and next steps.

Step 4:

Get ready to RESET!

Step 1:

Complete the Retreat Registration Intake Form. It's imperative that all fields include the appropriate information.

Step 2:

Payment is REQUIRED to submit this form. Responses are not saved unless the payment has been processed.

Step 3:

Once approved by our Team, you will receive a Welcome email / WhatsApp with information and next steps.

Step 4:

Get ready to RESET!

Your Information

Name

Phone

Email

Address

Date of birth

Month

Day

Year

Emergency Number and Relationship to this person

Why You're Coming

What do you need right now from this workshop? And what are you hoping to achieve?

Did you attend any workshops before?

Yes

No

Have you done breathwork before?

Yes

No

If yes, what was that like for you?

Who may we thank for referral

Family Status

What is your marital status? If married, Please describe the relationship as best you can. If single, describe your situation.

If you have children, take a moment to write their names, ages and your relationship with them.

Please describe the dynamics in your family of origin and your relationship to your parents:

Anything significant you would like us to know about any of your siblings? Please list their names and ages.

Health & Safety

Medical background

Do you have any physical or health limitations that the staff should be aware of?

Are you currently under the care of health professional for any reason - physical or mental? If yes, Please explain:

Do you have history of heart problems, seizures, asthma, stress or anxiety attacks that have required medical intervention

Are you taking prescription medication for any reason?

Are you currently working with a therapist, psychiatrist or coach? And if yes, has this been helpful? Please elaborate

Do you have any addictions? If yes, please elaborate

Were you physically, mentally or sexually abused as a child? If yes, please elaborate

Do you have a history or suicide attempts or making suicide plans or threatening suicide

Yes

No

Please describe if any overt signs of trauma that you experience( i.e. panic attacks, hyperventilation, withdrawing, disassociating, etc.)

Do you have any food allergies or special dietary needs?

Are you an observant Jew? While your religious observance will not be judged or criticized, we would like to have an idea of how you identify yourself

Consent

In order to participate in this workshop, it s important that you agree to 100% confidentiality concerning other participants and any information you hear on the weekend. Please sign for this agreement:

I agree and accept the confidentiality terms above.

Liability Release: The Awakening Retreat is a weekend for personal reflection and growth, not a substitute for professional mental health care or medication. By signing, i acknowledge responsibility for disclosing any prior mental health concerns.

I understand and accept the Liability Release terms outlined above

Digital Signature:

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DISCLAIMER: The information provided in this submission form is intended for internal use only. We assure you that the information shared will be kept confidential and will not be shared with any outside parties without explicit consent. By submitting this form, you agree to these terms.

What Happens Next

Once you submit your application, our lead facilitators team will carefully review your information. This process ensures we can provide the safest and most supportive container for your specific needs. Your privacy is paramount; all details are kept strictly confidential within our intake department.

Timeline

You can expect a response via email or WhatsApp within 1 -2 business days regarding your status.

Follow-up

In some cases, we may schedule a brief call to better understand your history and goals.