Sanctuary in Sacred Santa Fe Retreat Application

Fields marked with * are required.

Personal Information

Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone

Email*

Birth Date*

Place of birth

Occupation*

Relationship status

(married, single, etc.)

Photo*

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB.

Please attach a recent photo (taken within the last 3 months) in jpeg format

Your Spiritual or Metaphysical Journey

Do you have a meditative practice?*

Yes
No

Do you have a technique for mental / emotional processing?*

Yes
No

In 50 words or less, describe any extra-sensory faculty that you possess (eg. clairvoyance, clairaudience):

In the space allocated below, briefly describe your background in self-discovery:*

Medical and Psychological Background

We ask for the following information because it allows Victoria to gain insight into your background, conditioning, and current state of well-being. Your answers will be held in strictest confidence. The energies of this retreat will be strong. Because you will be working together to go beyond the limitations of your egoic structure, it is important for her to know beforehand if there are potentially any issues that may cause you undue distress during the retreat.

Do you have a chronic illiness?*

Yes
No

If yes, in 50 words or less, please describe:

Are you currently taking any medication?*

Yes
No

If yes, please describe

Have you, or any of your immediate family members, ever had any of the following experiences or addictions (check all that apply):

Person(s) to contact in case of emergency

Contact name(s)*

Contact email(s):*

Contact Phone(s)*

Date*

Upon acceptance

Upon acceptance of your application we will send you further details about the retreat and links to make your deposit and balance due payments.

Phone

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