First Name *

Last Name *

Phone *

Email *

How old are you? *

Which City do you live in? *

What is your occupation? *

What is your level of trauma you've been experiencing on a scale of 1-10. 10 being the most *

How would you rate your current mental and emotional state? On a scale of 1-10. 10 being the worst *

Have you attempted or regularly contemplate suicide? If so, how often and on a scale of 1-10, 10 being every day? *

Have you been diagnosed with any personality, psychotic, mood or other disorders? if so, which? *

What issues or concerns are you looking to deal with and address during this retreat? *

Are you on any medication? If so, which? *

How open minded are you? Are you open to holistic/spiritual ideologies? *

Are you aware that our mental health programs/retreats, unless otherwise stated, are all private and one-on-one. *

Yes

Are you currently seeing a psychologist/therapist? or have you in the past? *

Was there a specific Retreat Package you are interested in? *

What are your preferred dates? Please provide as many as possible *

Do you have any physical limitations or injuries that might prevent you from participating in yoga or climbing stairs? If so, please let us know and provide details. Kindly note that both of our suites require stair access. *

What is your maximum budget? *

Are you financially prepared to cover the expenses of the retreat? *

What is your commitment level? *

Do you require a payment plan or outside financing? *

Have you ever been admitted into a psych ward/Hospital? If so when and for how long? *

Can you confirm you will be attending by your own free will? *

Yes I am ready and am choosing to attend

No, my family/friends are convincing/forcing me to, I'm not ready

Have you attended a retreat before, if so when and what kind *

How many nights were you wanting to attend? Min 4+ nights *

Would you like to set up a phone call to discuss and book your retreat? *

Yes, I require a phone call to finalize my booking

No, I can book online

Do you have any addictions you have been struggling with? If so what substance is it and when was the last time you consumed it? *

Do you understand and agree that you must be sober from drugs or alcohol for at least 14 days before attending and that Vita Wellness is not a detox centre? *

Yes I agree and understand

Please be aware that most services will be done within the comfort of your own room. But may be done outside if weather permits or at another location if available. Please Note: There will be no group activities. Are you able to be left alone at night? *

Yes I am able to be left alone at night

No I am not able to be left alone at night

Are you ready and committed to follow through until the end of your Retreat program to fully heal and to experience the full benefits? *

Additional Comments

By submitting this form, I acknowledge that the information I provide is accurate and complete to the best of my knowledge. I understand that all personal information will be treated with confidentiality and used solely for the purpose of assessing my needs and providing personalized recommendations. I consent to the secure storage of my data and its use by Vita Wellness staff directly involved in my care. I agree that Vita Wellness is not liable for any unintended/accidental access, or disclosure of my personal information. *

Yes

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