Intake form

Name *

Email address *

What type of treatment are you seeking?

Please select at least one option.

Addiction Counseling

Art Therapy

Music Lessons

Business Courses

Pilates

Group Therapy

Meditation

What is your preferred method of contact?

What is your age group?

Do you have any previous experience with rehab facilities?

What are your primary goals for attending our facility?

Are there any specific activities you are interested in?

Please select at least one option.

Yoga

Nature Walks

Mindfulness Practices

Nutritional Counseling

Workshops

Do you have any dietary restrictions?

How did you hear about us?

What is your preferred accommodation type?

Additional questions or comments