-Ceremony Questionnaire-
Before submitting this form please make sure you review our full retreat information page at EpicSelf.com
Pura Vida!
Name *

Email *

Mobile Number *

What time zone are you in?


What date/s would you like to attend Ceremony?

Is this your first time attending this type of Ceremony?  If not, how many times have you attended?

Are you taking any prescription medication right now or have you taken any prescription medication in the last 6 months? If so please describe.

Have you experienced any serious illness or major trauma in the last 5 years? If so please explain.

Do you have any food allergies and/or any strict dietary protocols that you follow?

How would you describe your quality of life right now- stable, transitioning, upheaval, etc..? Please elaborate if you like.

Is there something that you are focusing on for this ceremony that you would like to share with us? (If not, that is absolutely fine)

Do you have any concerns or questions that you would like to express?

For Women: Will you be menstruating at the time of the ceremony?

For Women who may be on their cycle: How would you describe your cycle? - normal, painful, erratic, etc. ?

How did you hear about this retreat?

After reviewing your application we will ring you for a 15 min discovery call prior to an invitation to attend. What is the best time of day to reach you via phone?

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