Full Name

What is your current country of residence? 

How would you describe your current emotional and mental wellbeing?

Do you currently have any medical conditions or health concerns that may affect participation?
Yes / No
If yes, please describe:

Are you currently under the care of a healthcare professional (doctor, therapist, psychologist, psychiatrist)?
Yes / No
If yes, please describe:

Have you ever been diagnosed with a psychological or psychiatric condition?
Yes / No
If yes, please list diagnosis, dates, and current status:

Have you ever been diagnosed with, or experienced symptoms associated with:

• Schizophrenia

• Schizoaffective disorder

• Psychosis

• Delusional disorder

• Bipolar disorder involving manic or psychotic episodes

Yes / No / Unsure

If yes or unsure, please provide details and indicate if you are currently receiving professional support:

Are you currently taking psychiatric or psychological medication?
Yes / No
If yes, list medication, dosage, frequency, duration, and prescribing doctor.

Are you currently enrolled in the Intuitive Rebirth Practitioner Training online?

Do you currently work in the healing arts in any capacity? 

Please describe any experience that you have that feels relevant to this training. For example, other retreats, other modalities, spiritual experiences etc. Please be as detailed as you feel necessary so that we can get to know you better at this unique stage of your journey. 

What is your motivation for joining the next Intuitive Rebirth Practitioner Retreat? What do you hope to get out of this experience? 

Beyond a practitioner training, this retreat will be a deeply healing experience that unearths all that no longer serves you, to be transmuted back to love.

Is there anything that we need to know about your life journey to best guide and support you through this transformation experience? 

(We honour your privacy. We honour your vulnerability. Please share from your heart anything that feels relevant.)

For example: childhood trauma, grief, loss, sexual trauma, abuse, addiction, spiritual or religious trauma, medical trauma, other significant trauma.

What is your Whatsapp number? 

When you are an Intuitive Rebirth Practitioner, how do you envision yourself making an impact in the world? 

What are your dietary requirements?

“I confirm that I have fully and honestly disclosed all relevant physical and mental health information, understand that this retreat and practitioner training is not a substitute for medical or psychiatric care, accept full responsibility for my participation and integration, and release Rhiannon Heins, Intuitive Rebirth, and all affiliated parties from liability. I understand participation may be declined and a refund issued if I am deemed physically or psychiatrically unfit.”