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Within Wellness Studio

Private Wellness Retreat – Pre-Intake Form

Please complete this form honestly and thoughtfully. All information is kept confidential and is used solely to ensure our retreats are a supportive and appropriate fit for you.

Birthday
Year
Month
Day

Your Intentions & Current State

(Please share as much or as little as feels comfortable.)

How would you describe your current emotional and mental state overall?
Very stable
Somewhat overwhelmed
Experiencing ongoing stress or emotional challenges
Feeling significantly challenged and seeking deeper support
What areas are you hoping to focus on during your retreat?

(Please select all that applies.)

Mental & Emotional Wellness History

(This retreat is supportive and holistic in nature and is not a substitute for medical or psychiatric care.)

Are you currently receiving support from a therapist, psychologist, psychiatrist, or other mental health professional?
Yes
No
I have in the past
Have you ever received a mental health diagnosis you feel is relevant for us to be aware of?
Yes
No
Prefer not to say
At this time, are you experiencing thoughts of harming yourself or feeling unsafe?
No
I have in the past but I feel stable now
Yes (If yes, please note that we may recommend additional support before proceeding)

If you are currently in crisis or feel unsafe, we gently encourage you to seek immediate professional support or contact local emergency or crisis services.

Medical & Physical Considerations

Are you currently taking any medications that may impact your experience?
Do you have any physical limitations, injuries, or medical conditions we should be aware of?

 Please note: Our retreat accommodations require stair access.

Retreat Readiness & Logistics

Have you attended a wellness or healing retreat before?
How many nights are you hoping to attend?
4 Nights
5-7 Nights
Open to recommendations
Do you feel emotionally ready to engage in a private, inward-focused retreat experience?
Yes
Somewhat
Not sure
Are you choosing to attend of your own free will?

Lifestyle & Substances

Are you currently struggling with substance use that may affect your ability to fully participate?

Do you understand and agree that you must arrive sober and substance-free for at least 14 days prior to your retreat, and that Within Wellness Studio is not a detox or medical facility?

Financial & Scheduling

What retreat package are you interested in (if known)?

Please list multiple options.

Are you financially prepared to invest in this retreat experience?
Yes
I may require an option plan
Would you like to schedule a complimentary call to explore fit and next steps?
Yes, I would like a call
No, I would like to book online

Final Reflection

Consent & Acknowledgement

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that Within Wellness Studio offers holistic, somatic, and sound-based wellness services and does not provide medical, psychiatric, or emergency care. I consent to the confidential storage and use of my information for the purpose of retreat planning and support.

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