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Retreat Form Questions
First Name
Last Name
Email
Phone
What are your goals?
What challenges or obstacles have you been facing, and would you like to address them during our time together?
What specific outcomes would you like to achieve as a result of this retreat? (Example: less pain, more self-awareness, better focus, deeper connections, etc.)
What would you be disappointed about if your VIP Experience didn't include?
Are there any topics that you
really
want to cover with our time together?
How do you typically learn and process information best?
select
videos
written
walkthroughs
graphics
audio
Do you have any dietary restrictions or preferences we need to take into account? (Example: intolerances, allergies, religious exclusions)
How active are you currently?
Do you have any physical limitations you’d like us to be aware of?
Do you have any health concerns you’d like to share?
Are there any specific activities or exercises that you would like to incorporate into our retreat agenda? (Please note that we won’t be able to incorporate everyone’s suggestions, but we’ll do our best!)
Are you sensitive to the sun, grass, other?
Do you run hot or cold
Hot
Cold
Do you prefer your treatment rooms warm, cool or neutral?
Warm
Cool
Neutral
What has worked for you before to support your healing and wellness, if anything?
Are you aware where your body may need support?
Do you have any religious preference or requests for your healing retreat?
What is your most consistent form of self-care?
Massage, Chiropractic, Other
Friend Time
Alone Time
Journaling
Prayer or Meditation
Deep Breathing
Hugs
Other
Other
What self care would you like to do more consistently?
How is your hydration? How much water do you drink per day?
Have you been sleeping well? What is your sleeping routine?
How much do you exercise? Do you get your heart rate up each day for 20-30 min?
Do you have pain in your body? If so, tell me about it.
If your body had a voice, where would it say it needs support?
Does your body trust you?
What is your relationship with your body?
At War
At Peace
Neutral
Don't Know
Other
Other
When you are angry, how do you respond?
Do you feel like you are following your passions and purpose?
What is your relationship with the higher power or God?
Do you feel like there’s something missing from your life? Do you know what it is?
What do you most look forward to?
Is there anything else that you would like to share with us before we begin our retreat together?
Mailing address for me to send you small gifts
Submit
© Ruth Cummings | Body & Mind Coach 2025
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