Wellness & Lifestyle Assessment
Thank you for your interest in our exclusive Wellness Retreat. This experience is designed for individuals who are ready to reconnect with their food, nourish their bodies, and embrace a holistic approach to well-being. Through mindful eating, proper food selection, cooking for optimal health, yoga, sound meditation, and other wellness practices, our goal is to help you achieve balance in your mind, body, and soul. Due to limited spots, we are accepting applicants who truly need this experience and are committed to making lasting changes in their health and lifestyle. Please take a few moments to answer the following questions honestly. Your responses will help us understand your current lifestyle, wellness goals, and how we can best support your journey.
First
Last name
Address
Email
Phone Number
How would you describe your current eating habits? (e.g., home-cooked meals, fast food, balanced diet, processed foods)
home-cooked meals
Balanced diet
Fast food
Processed Food
Tell us about yourself
Do you have any dietary restrictions, allergies, or specific food preferences?
Yes
No
How many meals for you typically eat per day?
Select an option
1 Meal a day
2 or 3
4 or 5
More
How often do you cook meals?
How many hours of sleep do you get on an average night?
Select an option
Less than 5 hours
5 to 6
6 to 7
7 or more
What's the biggest stressors in your life right now?
How many hours do you work per week?
Do you practice any form of meditation, yoga, or mindfulness? If so, how often?
Select an option
Never
Daily
1-2 times weekly
3-4 times weekly
More
How often do you engage in physical activity or exercise?
Select an option
Daily
1-2 weekly
3-4 weekly
More
Never
Do you experience digestive issues, fatigue, or any other health concerns?
What are your main wellness goals for attending this retreat?
Better Nutrition
Stress Relief
Weight Management
Mental Clarity
Other
What does “wellness” mean to you, and what changes would you like to make in your life?
Why do you feel this retreat is the right fit for you at this time?
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