IMMERSION RETREAT application Name * First Name Last Name Email * Subject * What aspects of your life and purpose do you want to clarify? What strengths and challenges are you aware of that inform your life currently? What is true for you about your internal landscape? (your body, symptoms, thoughts, dis-ease, health/wellness) How do you access Presence in your body or life? What practices do you have that grounds and nourishes you? What practices are you drawn to that you would like to add in or desire guidance with? What is your relationship to herbs, supplements and or essential oils? Currently are you experiencing trauma on any level that you are tending to or want support on? Are you currently taking any medications? Are you currently seeing a therapist (psychiatrist, psychotherapist, bodyworker, acupuncturist)? How would you measure the quality of your health from a scale of 1-10 (low to high) on 4 levels: Emotional, Mental, Physical, Spiritual? What would you like to gain by taking this journey with me? Is there anything else that you would like to share with me that feels alive? Thank you!