Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
What wellness topics are you most interested in exploring?
*
What is your birthday
MM
DD
YYYY
Do you have any dietary restrictions?
*
How did you hear of us?
A friend or family member
Facebook
Instagram
Other
Yoga experience
Beginner
Intermediate
Advanced
Strengths - What personal qualities do you have which we can build upon at the retreat, or that would help you in reaching your goals? (e.g., good social skills, open to feedback, quick learner, etc) Describe:
Needs - What would help you achieve your goals? (e.g., coping skills classes, encouragement to opt out of scheduled activities, encouragement to participate in movement activities i.e. yoga/walking, quiet time alone, etc.) Describe:
Abilities - What skills or strengths do you possess? (e.g., specific coping skills, self-care strategies, etc.) Describe:
Preferences – What preferences do you have and/or who would you like involved in your retreat? (group based activities, quiet hours in the morning vs evening, specific coffees or tea, etc.) Describe:
Please share any additional information about you that would be helpful in curating a retreat (i.e. recent loss of a loved one, history of trauma, desire to work on anxiety or depression, parenting discussions, etc)
*
Having the option for a therapeutic massage at an additional cost is important to me
*
Interacting with animals is important to me
*
Lots of yoga options is important to me
*
I am uncomfortable in nature
*
I am flexible with my dates to accommodate my preferences
Thank you so much for choosing to share information to help us build a retreat specific to your wellness journey. Once the retreat is full or 30 days before the retreat, whichever happens first you will receive your schedule, driving instructions, check in details, etc.
If you have any questions in the meantime, please feel free to reach out!
Sincerely,
mesquite wellness
