Apply Now Form

BODY | MIND IQ Health Reset Retreat

We’d love to get to know you. This short form helps us understand where you are in your health journey and ensures this retreat is the right fit for you.

Name

First Name

Last Name

Phone

(###)

###

####

Age Range

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What brings you to this retreat?

Tell us about your current challenges or what you’d love to change in your health and life

Do you have any diagnosed health conditions, chronic fatigue, pain, or recent illnesses we should be aware of?

This helps us ensure safety and suitability, rest assured your information is confidential

Are you currently pregnant or experiencing an acute health flare-up?

Yes

What do you most hope to gain from this retreat?

e.g. rest, reset, energy, clarity, connection, emotional release, understanding my body better, etc.

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Have you practiced breathwork or somatic work before?

No, this will be my first experience

Yes, I've attended workshops or online sessions

I practice regularly

Room Preference

Shared Twin

Private Room (+ supplement)

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Confidentiality & Privacy Statement

Your privacy and emotional safety are at the heart of everything we do. All personal information shared in this form, during sessions, or throughout the retreat is treated with complete confidentiality. We do not share participant stories, images, or experiences publicly without explicit written consent. Photography and filming are not conducted during workshops to preserve your right to express yourself freely and authentically. By submitting this form, you confirm that the information provided is accurate to the best of your knowledge, and you understand this retreat is educational and not a substitute for medical care. Add your name below if you agree to the confidentiality statement and understand this retreat is for educational and wellbeing purposes only.

Apply Now Form

BODY | MIND IQ Health Reset Retreat

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