India Retreat 2025 - Apply here! - Vanessa Dietzel | Maximise potential and well-being

Name

Phone (mobile) number

Email

How did you find out about this retreat?

What are your main goals for attending?

What practices do you currently have for personal growth and inner awareness? (e.g., meditation, breathwork, journalling, etc.)

Are you currently seeing a mental health professional (e.g., therapist, counsellor)?

Yes

No

Have you been diagnosed with a mental health condition? If yes, please specify.

Do you take medication related to mental health? If yes, please specify.

Other medications

You don’t need to share details: have you ever experienced trauma that you are aware of (e.g., physical, emotional, sexual abuse, or other types of trauma)? If so, what healing and/or therapy have you undertaken around this?

Do you have any known triggers that may cause you to become highly distressed? If yes, please specify.

Do you have any specific needs around mobility, access or neurodiversity? If yes, please specify.

The retreat may involve breathwork, physical movement, touch (Ayurvedic treatments), emotional release practices and processing of past trauma. Do you foresee any problems participating in these activities? (All activities are optional). If yes, please specify.

Are you comfortable participating in group discussions?

Is there anything else you would like to ask or share in order to have the best possible experience on this retreat?

Booking information

Full name as written in your passport (this will be used to book included trains)

Nationality

Passport number

Passport expiry date

Passport issue date

Passport issue location

Date of birth

Address

Emergency contact (name and mobile phone)

Other relevant information for the retreat organisers

Payment

I would like to pay

Currency

GPB

EUR

Agreements

I confirm that

I accept that my place on the retreat is only confirmed upon receipt of the non-refundable deposit

I understand that the retreat is taking place in a country with different levels of comfort, hygiene and service than I may be used to

I take responsibility for my own health and wellbeing and will consider the guidance from the retreat facilitators, who endeavour to make the retreat as comfortable as possible

I will ensure adequate travel insurance (mandatory - disclaimer to be signed) and take responsibility for arranging my own visa to India

I agree to pay part of the retreat fee in India in Indian Rupees (up to an equivalent of EUR1,000)

By completing and submitting this form, I agree with and will abide by the India Retreat Terms & Conditions (click button below to download)