Name *

First Name

Last Name

Any concerns or special accommodations needed?

Please Include any dietary restrictions

Yes

No

What are the top three stressors in your daily life?

Select all that apply

Parenting/Household responsibilities

Work-life balance

Lack of personal time

Relationships

Social media/electronics addiction

Other

What topics would you like to see covered in this retreat?

Select all that apply

Stress management

Mindfulness & meditation

Balancing work and family life

Self-care strategies

Navigating relationships

Burnout prevention

Electronics addiction

Positive self-image

Saying yes to too much/overcommitting

Other