Information Request - Conscious Recovery Retreat

Our 7-Day

CONSCIOUS RECOVERY RETREAT

It is imperative that you fill out this Information Request Form to continue with your registration on the Conscious Recovery 7-Day Bali Retreat.

We are really happy to have you here and looking forward to the retreat!
Let us know if you have any questions HERE!

What's your first name?

Last Name?

What's the best email address for you?

What's your phone number?

And what's your city, state & country?

How did you hear about our Conscious Recovery Bali Retreat?

Please list the personal growth work you have participated in including therapy groups, spiritual retreats and individual therapy.

Please answer the following questions. Your answers will be read by the organizer and the process leaders and will be kept confidential. It is important to answer all questions honestly in order for us to help you decide if Conscious Recovery is an appropriate group for you. Thank you.

Please indicate any physical, mental, psychological conditions or illnesses you or your immediate family members have had in the past or have in the present which required or require on-going medication and or treatment.

Briefly write about why do you want to do the Conscious Recovery Bali Retreat?

Anything else that you would like us to know?

I represent that all of the information provided in this form is true and correct to the best of my knowledge.

Please Note: As this form will only submit if all fields have been filled out, please make sure you have completed them all. If a question does not apply, you can write "Does not apply".

Thank you so much for submitting the Information Request Form. We'll contact you soon with more details about the Conscious Recovery 7-Day Bali Retreat. Firebird Healing & Conscious Recovery Team.