Retreat Application - Aya Divine Love
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Retreat Application

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BRAND_hawaii-holistic-retreat1000

THIS INFORMATION WILL NOT BE SHARED WITH ANYONE OUTSIDE OF OUR HOLISTIC RETREAT TEAM

 

What retreat are you applying for? (required)
 Ancient Fertility Retreat Pure Magic Retreat Rawfully Alive Retreat Kauai Goddess Retreat Sacred Amazon Journey Custom Retreat

What month(s) are you interested in coming to Kauai? (required)
 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 Another Month in 2017

Your Name (required)

Your Email (required)

Referred by (required)

Your Address

Your Phone Number (required)

Your Skype User Name or  I do not have a Skype user name

Your Time Zone (required)

Your Age (required)

Emergency Contact Name (required)

Emergency Contact Phone (required)

Primary Personal Reason for Retreat (required)

What would you like to accomplish during your retreat? (required)

Have you had shamanic or spiritual healing/ energy work before?
 Yes No

Was it a positive experience?
 Yes No

Please share any physical, emotional or spiritual conditions, symptoms or concerns you are currently experiencing. (required)

When did these begin? (required)

Any major stressors occurring at that time? (required)

Describe what activities cause the above and/or make it worse: (required)

Please list medicines, drugs, herbs or supplements you are currently taking: (required)

Describe any surgeries, hospitalizations, accidents, injuries, illnesses, major stressors or traumas you have had including your age at the time: (required)

What kind of care did you receive for the above? (required)

Do you feel that you have recovered from these events? (required)

Are you currently under the care of a physician or other health care provider/therapist/healer? (required)
 Yes No

Whom? (required)

What is Their Phone?

Please list reason(s) that you are under their care: (required)

Does Aya have your permission to consult with them regarding your care, if needed?
 Yes No

Are there any other physical, emotional or spiritual concerns you wish to work on, in your retreat? (required)
 Yes No

If yes, please describe: (required)

Are you pregnant?
 Yes No

Do you want to be pregnant?
 Yes No

Are you allergic to any plants/ herbs/ supplements?
 Yes No

Are you allergic to airbornes?
 Yes No

What are your favorite scents? (required)

What are scents you’d rather avoid? (required)

Are you allergic to/ bothered by incense smoke?
 Yes No

Is there anything else you’d like me to know? (required)

 

Client Confidentiality and Release Agreement

I understand that all modalities offered through Aya Divine Love are not replacements for medical care. The practitioner, a licensed massage therapist and shamanic practitioner, does not diagnose or treat mental or medical illness, disease or other physical or mental conditions. As such, the practitioner does not prescribe medicines, nor does he/she perform spinal manipulations. Any mention of herbs and nutrition are for educational purposes only. It is the client’s responsibility to research herbs and supplements and check with their primary health
care provider before taking them. It is my, the client’s responsibility to consult the appropriate licensed health care professionals for treatment of any mental or physical disease, symptoms or concerns that I may have. I agree to take responsibility for my own health and my own response to shamanic healing and I agree not to hold the massage therapist responsible for any unwanted results in my life after receiving a session from her. The practitioner may recommend referral to a qualified physical or mental health care professional for any physical or emotional conditions I may have that are out of her scope of practice. I have stated all my known physical and mental conditions and take it upon myself to keep Aya Divine Love updated on my health status during the leading up to and during my Kauai Holistic Retreat.

 

By sending this form, I agree to the above conditions and that my answers are truthful to the best of my knowledge at this time.

 

 

THIS INFORMATION WILL NOT BE SHARED WITH ANYONE OUTSIDE OF OUR HOLISTIC RETREAT TEAM