ARUNA INTAKE FORM

We are excited to have you join us for this magical and deeply transformative journey with us in Berlin. The safety of our guests is our main priority and therefore we would like to ask you to please take some time to answer the following questions for us.

Name

First Name

Last Name

Phone

(###)

###

####

Adresse

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Comments or Special Needs

Do you have any dietary restrictions?

Flight Arrival Information

What are looking to achieve during your retreat?

Please let us know why you are coming. What are looking to heal, let go off, learn about yourself while you are here? Anything you share is kept confidential.

Who is willing to support you during the integration period?

Are you interested in ongoing integration support with one of our facilitators?

Tell us about any medical issues that we should be aware of

For example: asthma, diabetes, epilepsy etc

Have you had or do you currently have any mental illness that we should know about? (Bipolar, schizophrenia, dementia)?

Please list any antidepressants or antipsychotic medications that you currently take?

Trauma History: Have you experienced any very difficult or stressful life experiences or events? (witnessing or experiencing firsthand)

Do you have any heart conditions? Please explain.

Please detail your alcohol or recreational drug use?

Do you have any addictions?

Are you taking any other medications?

Emergency Contact (First & Last Name, telephone number and relation to you)

Anything else we should be aware of?