Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Preferred Retreat Date *

Patrick to supply date options

MM

DD

YYYY

What are your primary goals for this retreat? (Check all that apply):

Reconnecting with myself

Healing from stress, anxiety, or trauma

Deepening relationships

Physical wellness and relaxation

Exploring creativity and self-expression

Learning new wellness practices

Other

Do you have any experience with the following? (Check all that apply):

Meditation

Yoga

Sound Therapy

Art or Music Therapy

Journaling or reflective practices

None of the above

Are you currently under the care of a mental health professional? *

Yes

No

Have you ever been convicted of a crime? *

This is asked to ensure the safety of all guests and our home environment.

Yes

No

Do you have a history of substance abuse or addiction? *

Yes

No

Consent and Agreement By submitting this form, I confirm that the information provided is accurate and truthful to the best of my knowledge. I understand that the Sanctuary Retreat is a private wellness experience and agree to uphold the shared values of respect, trust, and community during my stay.

I acknowledge and accept that the Sanctuary Retreat reserves the right to decline applicants whose needs may require professional therapeutic or medical attention beyond the scope of the retreat’s expertise. (click this box to confirm)