Medical Form

Congratulations on choosing this transformational
Initiation / Immersion for yourself and those you serve.
Please take a moment to fill in the details below about your medical history. 
This is strictly confidential & will only be used in the event of an emergency.

Are you taking any medication?
Have you ever suffered from any of the following?

PLEASE NOTE: During this immersion, we will be partaking in daily yoga, somatic movement, dance, wáter dance, drumming, and a hike to one of Bali’s largest waterfalls. Although EVERYBODY is welcome to join some level of physical & psychological fitness will make the immersion more enjoyable for you!