Name:

Age:

Marital status

Children:

Age of children

Are you working full time / part time / unemployed / housewife:

For what reason are you coming to the retreat?

What would you like to gain or learn from the experience i.e. to love yourself, lose weight, etc

1

2

3

4

5

What traumas have affected you life since childhood and have you had support?

Do you have any experience of group therapy and what do you expect from the group?

Do you have any special dietary needs, allergies, medications, ect?

If you have serious mental problems and are already being treated by a psychiatrist or psychologist, this treatment may not be right for you. It is important for you to consult your doctor beforehand.