RETREATQUESTIONNAIRE Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Birthday * MM DD YYYY Exact Birth Time + Location * Choose An Animal Lion Dolphin Eagle Turtle Snake Wolf Choose A Color * Orange Red Blue Yellow Green Purple White Food Allergies / Dietary Restrictions * Breakfast, Lunch and Dinner will be provided. You may bring snacks if you desire to eat any other food during the day. Do you eat meat? * Yes No Do you eat gluten? * Yes No Medications / Medical Conditions * Emergency Contact Name + Phone Number * Please list the parts of your physical body that cause you pain or discomfort. * When I say the word "God" what does that mean to you and/or how does that make you feel? * When I say the word " Sexuality" how do you feel? * Describe in a few sentences the reality you see happening around you within the world. * Let's type it out : At the end of our time together, what do you desire to both let go of and embody within your experience? * When you close your eyes and meditate, what do you see or feel within you? * Please share below any other information you feel we should know or would like to share. * By typing your name below you understand that Britt Johnson, co-hosts and organizers cannot guarantee results or healing outcomes. Your privacy is securely protected in this space and your well-being both emotionally and physically are of the highest importance. You have freely chosen to particpate in this gathering and are fully in control of what you do and do not wish to partake within. * Thank you!