Butterfly application | Zen Jungle Retreat

First name

Last name

Email

Phone

Choice of Retreat

Target Arrival Date (Earliest 9/9/24)

Stay Length

Accomodation choice

Dietary Requirements

Which of the following 32 things do you most relate to?

On a journey to a different life

Overthinking, Worry or Anxiety

Exhausted, tired of the "rat race"

Trapped, need to escape

Can't sleep, thinking all night

Addicted or compulsive

The world's gone mad, change it

Low self opinion, self hatred

Isolated or alone, want to belong

Voice in the head, depression

Looking for a way out, suicidal

Guilt, blame, a victim

Overcome by fear, fear of death

Grief, loss, deep sadness

Chronic pain, mental or physical

Terminal illness

Unable to overcome "Trauma"

Dependency in relationships

Need a soulmate or twin flame

Problem and failed relationships

“Toxic” or abusive relationships

Inability to trust, insecurity

Lack of self confidence

Anger, poor impulse control

Want to find peace, to relax

Want or need to be free

Want to find meaning or purpose

Unhappy, want to find happiness

Spiritual growth and connection

Seeking to awaken, you or others

Want to find connection

Want to find flow and intuition

Seeking enlightenment

Wanting to transcend it all

Other

Reasons you relate

What is your primary goal?

Primary Goal

Do you have a history of any of the following :

Details of history

Do you have any physical or mental disabilities?

Anything else important we should know about you?

Please note that the contents of this form will be kept strictly confidential. Be honest, your answers are used to assess how to maximise your benefit from the program and do not risk exclusion.

BUTTERFLY PROGRAM REGISTRATION

If you have further questions?

Register to Stay

Once we receive your registration and check availability for your chosen accomodation and dates, we will send a booking confirmation or have a call to discuss options.

JUNGLE COMMUNITY

& RETREAT CLUB

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