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Gaian Rhythm

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Recipe Gaian Rhythm 4/28/20 Recipe Gaian Rhythm 4/28/20

Pea and goat cheese crostini

PLEASE READ BEFORE PROCEEDING

Registration is simple. First, fill out the registration form on this page. Once your form is submitted we will review it and reach out to you via email with instructions and additional details. This may happen in as little as an hour or as long as a week depending on our schedule.

REGISTRATION IS OPEN ONLY FOR OUR MID-WINTER WEEKEND RETREAT IN JOSHUA TREE, CALIFORNIA

NO OTHER APPLICATIONS WILL BE ACCEPTED.

* Please make sure the email address you provide is accurate or we will not be able to register you*

TO VISIT OUR PRIMARY WEBSITE PLEASE GO TO GAIAN RHYTHM .COM

Name *

First Name

Last Name

Email *

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

What city and state do you live in?

Have you served in any branch of the Military? *

yes

no

Have you ever attended a sacred vine ceremony before? If so how many and where? *

Have you experienced other consciousness altering states, meditation or shamanic retreats? *

if yes please describe, otherwise simply write "no"

Are you currently pregnant? *

yes

no

Are you currently taking any medications? If so please list and state how long. *

Some medications are contraindicated, for your safety honesty is important.

Are you able to stop all medication prior to the retreat? *

Please consult your treating physician before stopping any medication or treatment plan

Please list any natural remedies you substance you take *

This includes Kratom, cannabis and micro-dosing

Have you ever been hospitalized for any psychiatric or emotional issue? Is "yes" please list when, why, and any diagnosis given *

Please give an overview of any medical conditions or concerns you may have *

(ie high blood pressure, heart conditions)

Please describe any history of mental health diagnosis, treatment, or concerns *

Have you ever or do you currently struggle with substance abuse? *

If yes please list length of sobriety or active use

Do you have any food allergies? *

If you attend one of our retreats this info will be passed on to the chef.

Please list any dietary restrictions.

ie vegan, vegetarian, celiac etc

What do you hope to take away from this experience? *

Do you serve or facilitate any kind of healing modalities? *

meaning do you provide services for others i.e Reiki, breathwork, yoga, or serve plant or animal medicines etc.

Is there anything else you'd like to add or feel we should know?

Do you have any questions or concerns?

I attest that the above information is true to the best of my knowledge *

yes

Thank you! We will email you soon from hello@gaianrhythm.com