Retreat Booking Form | The Art of Meditation

Neuro Reset Application Form

Dear Friends

You have reached this page to apply for one of the Reset Retreat Programmes available. This may be for a fixed retreat date for a small group, or a flexible date booking.

Please complete the form below (always be treated confidentially) so that we may assess your suitability and advise you appropriately.

Name

First Name

Last Name

Email

Date of Birth

MM

DD

YYYY

Gender

Please select a menu type

Do you have any allergies we should be made aware of?

We aren't able to cater for complicated diets but will do our best to fit you into our simple menu. Please let us know of any life threatening allergies you have.

Have you been on retreat before with Burgs?

Yes

No

If YES, please let us know what retreats or online courses you have completed with Burgs.

Please detail any current physical or mental health conditions for which you are receiving treatment for

Are you currently taking any prescribed medication?

If yes, please give some details

Please give details of any past mental health conditions you have struggled with (diagnosed or not)

Write a statement of intention.

A few words about why you feel this retreat programme would be beneficial for you. What is it that prompted you to apply? What specific aspect to the programme resonated with you? etc etc.

If you have any questions then please do contact us.