Registration Form

Your Full Name *

Your Email *

Contact number (incl. whatsApp if you use it):

Your Skype name:

Nationality:

Current place of residence:

Date of birth:

Your Gender:
---MaleFemale

Are you fluent in English:
YesNo

---

Choose the duration of your stay in Ubud:
3-5 days5-7 days7-10 days10-14 daysmore than 14 days

Choose the level of accommodation (single occupancy, central location):
Local Budget: approx. US$30.00/night2-star: approx. US$85.00/night3-star: approx. US$130.00/night4-star: approx. US$165.00/nightVilla with a private pool: approx. US$200.00/nightNo accommodation

---

Select the type of sessions you would like to experience during the retreat if you are familiar with different modalities. If not, we will be happy to suggest selected modalities and explain the details to you:

Body therapies: you can out as many in one line as fits
Private yoga classAcupunctureAcupressureNutrition consultationJuice/ raw food detox and cleanseNutrition consultationHolistic doctor consultationNaturopath consultationLive blood analysisHydrocolonotherapyBodyworksHealing massageAyurvedic consultationKinesiology sessionChiropractic session

Mind-focused modalities:
Timeline Therapy – exploring the roots of basic emotions and beliefs in your life and releasing/ shifting them.Private meditation classesHypnotherapy sessionNLP SessionThetaHealing - working with your subconscious to identify the patterns, blocks, beliefs and change them.

Energy, psychic and multidimensional modalities:
Individual breathwork sessionIndividual Family Constellations sessionPsychodrama sessionReiki sessionCranial-Sacral energy healing sessionIndividual Sound Healing sessionEnergy healing massageEnergy activation and energy blocks release work with a psychic

Readings:
Tarot ReadingAstrology ReadingMayan Calendar ReadingChanneling session

Other activities:
Cooking classArt and handcraft classSightseeing tourSurf lessonDiving or snorkeling tripMountain bike tripBatur or Mount Agung sunrise hike

Others:

---

Special dietary requirements:

Medical conditions we should be aware of (incl. medications you take):

What are your biggest personal challenges you intend to shift during the retreat:

What are your personal goals for the retreat:

Do you have a spiritual practice (if yes, please tell us about it):

Please tell us a few words about yourself, your lifestyle, interests and about what inspires you:

How many times have you been to Bali before:

Have you attended other retreats in the last 2 years (if yes, which ones):

Where did you find out about the retreat from:

Please give us your flight information for aiport pick up/drop:

Your additional comments, requests or questions:

After receiving the information of the length of your stay, type of sessions and activities you would like to experience as well as why you are coming to this retreat in the first place – what would you like to focus on and change in your life – we will create an individual package for you. We will be open to any modifications until you are happy with the content and the investment you are making.

Here are the packages mostly selected by our Customers:

SIMPLE PACKAGE: Budget accommodation with a breakfast 60min consulting onboarding session 1 private healing session/treatment/reading per day 1 extra activity/ day (yoga/ meditation, others) Retreat workbook Airport pick up and drop Local sim with internet data

I’M WORTH IT COMFORT PACKAGE: 3* Accommodation with a healthy breakfast 60min consulting onboarding session 60min summary and further recommendations session 2 private yoga classes 1 private healing session/treatment/reading per day 1 extra activity/ day (yoga/ meditation, others) 3 amazing spa treatments of your choice (1 massage in your room) Airport pick up & drop Local sim card with internet data Gift back Retreat workbook 1 bottle of a green juice/coconut or alkaline water in you room daily Scooter taxi or scooter rental

3 days package: USD $800 Each extra day: USD $250 7 days: USD $1750

3 days package: USD $1350 Each extra day: USD $450 7 days: USD $2999