Application/Intake Form

Apply here

🌿 Personal Information

First name

Last name

What name do you prefer to be called?

Email

Phone

How did you hear about us?

Friend

Social Media

Other

Instagram Handle (optional):

Birthday

Month

Day

Year

Time of Birth

Time

HoursMinutes

This is useful in 1:1 sessions with us.

🌿 Retreat Selection

Which retreat are you applying for?

Group 1: July 11–16, 2025

Group 2: July 25–30, 2025

I’m flexible, either dates work for me.

📦 Retreat Packages

Scroll below application to see full packages.

🌿 About You

What called you to The Calm Surrender Retreat

What are you most seeking to release, heal, or reconnect to at this time in your life?

Have you participated in retreats, therapy, or emotional healing work before?

No

Yes

Some, but I’m new to deep emotional work

Do you have any medical, emotional, or mental health conditions we should be aware of to best support your journey?

🌿 Logistics

Dietary Neeeds

If "other" was selected for dietary needs, please specify.

Transportation Support: Would you like help coordinating transport from nearby airports?

Yes

No

Emergency Contact Name/ Relationship to you

Emergency Contact Phone #

Who Referred You?

🌿 Payment Agreement & Acknowledgements

I understand a $300 non-refundable deposit is required to reserve my spot.

I understand I may choose to:

Pay my remaining balance in full by June 30, 2025.

Pay my remaining balance in two installments: by June 30, 2025. (June 1st, June 30th)

Pay my remaining balance in three installments: by June 30, 2025. (May 15, June 1st, June 30th)

I understand the full retreat amount must be paid before arrival.
I understand that spaces are limited and rooms are assigned based on availability.
I acknowledge that this retreat includes plant medicine experiences (optional) and will require me to act responsibly.

I agree to the terms above.

Identity Verification

Please upload a clear photo of a government-issued ID (driver’s license, passport, or national ID card).

This is for safety, verification, and administrative purposes. Your information will be securely stored and permanently deleted

🌿 Final Reflection (Optional)

If you could describe your current emotional or spiritual state in one word, what would it be?

Once your application is reviewed and deposit is received, we’ll reach out to confirm your space and send your payment schedule and retreat instructions. We reserve the right to decline an application if we feel that this retreat may not be the right energetic fit for your growth at this time. Should that be the case, your deposit will be fully refunded.

Deposit to hold your spot.

$300

Thank You

We’re honored to walk this sacred journey of surrender and renewal with you.

With love and tenderness,

Kiuna & Mario, Calm Surrender Retreat Facilitators

Retreat Packages

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