Phone Number

Email Address

Date of Birth

Height:

Weight:

Please, describe your past health history:

i.e., medications, injuries (past or present), nervous or psychological disorders, anxiety, previous or current injuries, mobility issues, let us know if inclines or stairs are a challenge for you, etc.

How would you consider your current state of health?

Do you have any current health complaints, symptoms, or any kind of pain (where)? If yes, please give us information about what kind, which intensity and frequency of the symptoms and/or pain:

Do you take any prescription medications? Which ones and for what purpose? Since when?

Dietary needs or limitations?

Emergency Contact Person Name and Phone Number

Relationship Status:

Nationality and/or religious and/or spiritual background:

How will you be arriving?

Arrival Time

When would you like to arrive? First time visitors should arrive between 2-3pm. Let us know if this is not possible.

Departure Time

This helps us create the most well rounded routine for you to your last day.

How will you be departing?

What kind of car will you be driving? Our access road can be snowy/muddy. 4 wheel drive, good ground clearance is highly recommended. We will be in touch about the best place to park if we feel your vehicle is not well suited for our road.

Where will you be traveling from?

This information allows us to know your travel time and your route to the Ashram. USE THE DIRECTIONS provided under "Contact". GPS is VERY unreliable. Google Maps thinks that a logging road that does in fact lead to the ashram is an actual road. It is not passable unless you are in a very large truck. We have had to pull people out of the mud/snow on numerous occasions, after we drive 30 minutes to locate them. PLEASE HEAD THIS WARNING. The Ashram is not hard to find IF you use our directions! You will be emailed the link to our directions once your stay is confirmed, or they can be found under "Contact" on our website. If you follow your GPS and get lost we reserve the right to charge you a minimum of $25/hour to come find you. (Yes, that is how much people don't listen, follow their GPS and get hopelessly lost and/or stuck.) Thank you for not doing that!

Where do you live (if different from above)?

What is your current job or occupation?

The more we know about you the more we can give you while you are with us!

If you answered 'No' to the last question, please help us understand the reasons why you are not satisfied with your current job/occupation:

Do you receive any kind of therapy?

a. Which Kind? b. What is the purpose? c. Which is the frequency? d. Since when?

Have you been facing any kind of emotional issues (i.e. anxiety, depression)?

a. How often? b. Any reasons or factors causing the condition? c. Since when?

Do you experience fatigue?

a. How often? b. At what time in the day? c. Since when?

Do you use any kind of recreational drugs? (i.e. cigarettes, alcohol, cannabis)

a) Which ones? b) How often? c) Since when?

Do you take any supplements?

a) Which ones? b) For what purpose? c) How often? d) Since when?

Describe in details *(please, be honest for best assessment):

a) What are your daily eating habits (i.e. what do you eat in each meal and at what times) ? b) what kinds of foods do you consume in a “perfect” diet day for you? c) what kinds of foods do you consume in a “bad” diet day for ?

Please, describe your bowels movements:

a) With which frequency do you go to the bathroom in a day? b) Which is the consistency of the stool? c) Which color and intensity of the smell?

Describe your sleeping patterns:

a) At what time do you go to bed? b) Do you sleep through the night? c) Do you wake up constantly? d) Any other details?

Do you have any exercise routine?

a) What kind of activities? b) How many times in a day, or week or month? c) For how long do you practice at each time?

What kind of professional activity do you perform?

a. How many hours/day do you work? b. Since when?

What is your goal by enrolling in our Nadi Vaidyam Program?

Why were you looking for a retreat?

What is your current Yoga/Meditation/Spiritual practice experience?

What do you hope to get out of this Retreat?

Do you have any experience being off grid and/or fully immersed in nature?

We ask because some people find themselves uncomfortable without access to wifi, central air, traditional plumbing, etc and we like to be sure you will be able to fully enjoy your stay!

Do you anticipate you will find it challenging to be so far from "city life" and the modern comforts it offers?

Our accommodations are very comfortable, but there is minimal access to electricity. We have composting toilets and hand pumped water and hot showers. We don't want you to arrive and get a unwelcome surprise!

What made you choose us?

Payment

Where did you hear about us?

Just curious!

Healing Retreat Registration