The time is now. 

The Loveolution starts here, with you. Thank you for helping us guide you. 

I am completing this Confidential Medical History Form in order to ensure the safety of myself & all those participating in the Meditation Retreat. The information provided on this form will be used for the sole purpose of determining the appropriateness of my participation in the Meditations.

Full Legal Name *
Full Legal Name
Gender
Address
Address
Please answer every question and if not applicable, please answer with “N/A”. Please elaborate on any “yes” answers or arrange to speak via phone or Skype before the retreat.
Are you pregnant?
Have you been in counseling with a psychiatrist, psychologist or other counselor?
Do you have, or have you ever had, substance abuse problems, whether or not it required hospitalization or participation in a rehabilitation program?

Have you ever been hospitalized for a psychological or emotional problem?