Heart of the Mother Retreats

Health Questionnaire and Motivation Form


For participation in this work of direct experience, deep insight, self awakening, and healing, we need to consider your past experiences and medical history. The information you provide to us will be used to determine if participation in The Heart of the Mother Retreat is appropriate for you, and will help us to provide better individual attention and guidance.  Your privacy is very important to us, and we assure you that all information contained herein will remain strictly confidential. 

Please complete EVERY item in every section before you submit the form!  In addition, upon completion of the registration form, you will be asked to submit a deposit of $100 to secure your space in the retreat.