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Retreats: Health Check Form

Thank You for your interest in our Psychospiritual Retreats

This health check form is for all of our retreats.

In order to register your interest and book a place at an upcoming retreat, we first have to take you through the consultation process to ensure the experience is suitable for you.

Please carefully complete the health check form below and we will get back to you as soon as possible to arrange a chat with you. Provided all is ok, we will get you booked in for a retreat and provide payment details.

It's important that you take the time to complete this form with care and please be honest and clear in your responses. All information is confidential.

Please note, if you have been on a retreat with us before, you do not need to complete this form again. You may email us directly at [email protected] to book again.

Your Information

Contact Details:

Which retreat/ceremony date are you interested in attending?

What's the best time of day to arrange your consultation call? (Between 9am and 5pm, Monday to Friday)

Health Questionnaire

What's your Date of Birth?

Have you ever had a serious heart problem?

If yes, please specify:

Have you ever had a stroke?

Are you on any medication for low blood pressure?

Have you ever had a brain haemorrhage?

Have you ever had an aneurism or blood clot?

Do you suffer with serious mental health problems (excluding depression or anxiety)? If yes, please provide more details:

Are you on any medication for anxiety or depression? If yes, please name any medication(s) below:

Is there a family history of mental health illness?

Have you ever experienced a psychotic episode?

Have you ever experienced a panic attack?

If yes, please provide more details:

Are you undergoing, or have you undergone in the past 6 weeks, chemotherapy or radiotherapy?

Are you taking immune suppressant for organ transplant?

Are you taking other immune suppressants?

Are you taking slimming, serotonin, or sleeping supplements? If yes, please name them below:

Are you currently or possibly pregnant?

Are you breast feeding a child?

Do you have Addison's disease?

Do you have Ehlers Danlos Syndrome?

Do you have Epilepsy?

Are you recovering from a major surgical procedure (within 6 weeks)?

Are you under 18 years old?

Have you had a Covid vaccination?

If yes to Covid vaccination, please provide us with the following dates in the box below - date of 1st vaccine, date of 2nd vaccine, & date of booster(s):

Have you received Botox in the last 3 weeks?

Do you have a drug or alcohol addiction?

Are you fasting or water fasting?

Do you have Boerhaave's Syndrome or have you suffered from Spontaneous Rupture of the Oesophagus?

Have you suffered injury or trauma to the Oesophagus/Escophagus from endoscopy?

Have you had a tumour in your throat?

Have you had an ulcer in your throat?

Have you suffered physical trauma or injury to your neck?

Have you had Bulimia?

Do you suffer from Gastro-intestinal Reflux?

Do you have a history of smoking?

Do you suffer from chronic inflammatory response syndrome due to mould exposure?

Do you have untreated eosinophilic esophagitis?

Do you have Diabetes?

If yes to Diabetes, please let us know if you have Type 1 or Type 2?

Do you have a Gastric Band?

Do you have any other conditions or are you on any other medication that we need to know about? If yes, please state below:

Please note that by submitting this form you are agreeing to be contacted by Julia² by email. You will have the option to opt-in to our newsletter and can unsubscribe at any time, but we need to be able to contact you to arrange your consult call and retreat attendance.

** We are away from Wednesday 2nd October 2024 and so will be out-of-office for a little while, but we will pick up your form submission when we return to work on Monday 21st October and get back to you ASAP **