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* 1. Please provide your full name.

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* 2. What is your phone number?

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* 4. Where do you currently reside? (Town/Province/Country)

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* 5. Which Retreat option(s) are you interested in attending? Select all the Apply

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* 6. What is your preferred method of contact?

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* 7. Which of the following have tried the past?
Check all that Apply

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* 8. Have you had experiences with a therapist or licensed counsellor in your wellness journey? If yes, and you would like to share some of the practices that you have adopted, please give details here.

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* 9. Have you had experiences with a certified coach in your wellness journey? If yes, and you would like to share some of the practices that you have adopted, please give dtails here.

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* 10. Now that you have described what you have tried in the past and is working/has worked for you, can you please explain some practices that did not serve you and thoughts on why that might be?

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* 11. How did you hear about our retreats?

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* 12. When you think about what WELLNESS means to you, what would be a result or outcome of this weekend that would be a "WIN" for you?

Thank you for providing your information and interest in our Grounded Wellness Retreat!

You will be contacted via your prefered communication
method within 3-5 business days of submitting this intake form.

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