Begin Vikasa Retreat Application Form

Your Name(Required)

*FIRST NAME *LAST NAME

*AGE(Required)

*DATE OF BIRTH(Required)

*EMAIL ADDRESS(Required)

WELLNESS, LIFESTYLE AND GOALS

*WHAT ARE YOUR MAIN GOALS FOR THIS PROGRAM?(Required)

*HOW WOULD YOU RATE YOUR PHYSICAL HEALTH ON A SCALE OF 1-10?(Required)

*WHAT IS THE MOST IMPORTANT THING YOU WOULD LIKE TO CHANGE ABOUT YOUR DIET TO IMPROVE YOUR HEALTH?(Required)

*HOW WOULD YOU RATE YOUR MENTAL HEALTH ON A SCALE OF 1-10?(Required)

*IS STRESS CURRENTLY AN ISSUE IN YOUR LIFE, IF SO, HOW?(Required)

*WHAT IS YOUR OCCUPATION AND HOW MANY HOURS DO YOU WORK PER WEEK?(Required)

*WHAT WOULD A TYPICAL DAY OF EATING/MEALS LOOK LIKE FOR YOU?(Required)

*DO YOU HAVE ANY CRAVINGS OR ADDICTIONS YOU WANT TO ADDRESS?(Required)

*HOW IS YOUR SLEEP? HOW MANY HOURS DO YOU SLEEP PER NIGHT?(Required)

*DO YOU HAVE ANY REGULAR HOLISTIC THERAPIES?(Required)

*HOW MANY TIMES A WEEK DO YOU EXERCISE?(Required)

MEDICAL

*ANY CURRENT OR PREVIOUS SERIOUS ILLNESSES, HOSPITALIZATIONS, OR INJURIES?(Required)

*ANY ALLERGIES OR SENSITIVITIES?(Required)

*LIST ANY CURRENT SUPPLEMENTS OR MEDICATIONS YOU ARE TAKING:(Required)

YOGA EXPERIENCE

*HAVE YOU DONE YOGA BEFORE? OR HOW LONG HAVE YOU BEEN PRACTICING YOGA?(Required)

*DO YOU HAVE A REGULAR YOGA PRACTICE? IF SO, HOW FREQUENTLY DO YOU PRACTICE YOGA?(Required)

*DO YOU MEDITATE? IF SO, HOW OFTEN AND WHAT TYPE OF MEDITATION?(Required)

*DO YOU HAVE A PRANAYAMA (BREATH WORK) PRACTICE? IF SO, HOW OFTEN AND WHAT TYPES OF EXERCISES?(Required)

*WHAT ARE YOU MAIN YOGA GOALS FOR THIS PROGRAM?(Required)

ADDITIONAL COMMENTS/ANYTHING ELSE YOU WOULD LIKE TO SHARE?

RETREATS

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Begin Vikasa Retreat Application Form | Vikasa