Guest Information Form

Please use this form to provide us with any information about yourself that you think we need to know in order to enhance the quality of your retreat experience @Harriet’s House

Guest's Name

First Name

Last Name

Your Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of the Retreat you have booked

MM

DD

YYYY

The food on the retreat will be vegetarian / vegan depending on guests' preferences. Please tell us about any food allergies or intolerances that you have. Please also let us know what foods if any you really don't like.

Skin Allergies

Please tell us about any allergies to skin care products that you are aware of (We will be using Neal's Yard Products)

Any other allergies

e.g. bee or wasp stings, medications

Medical Health

Please tell us about any medical conditions, prescription medication or any chronic conditions that may affect your ability to access and participate freely in the content, activities and environment of the retreat? There is a house dog called Pip who usually sleeps and occasionally barks. There are some winding stairs in the house that have no handrail.

Mental Health

Our aim is to provide a safe and supportive environment for everyone so we kindly ask you share any relevant information about any past or present serious mental health issues (e.g. psychotic or psychiatric illnesses) that might affect your participation.

Please indicate which treatment you are intending to receive (tick one)

Indian Head Massage

Reiki & Crystal Energy Rebalance

Tarot Card Reading

Finally please use this space to share anything else with us that you would like us to know.

Photographs and Video

Please confirm here if you are happy for photographs and videos to be taken during the retreat and used at a later date for future promotional purposes

Yes I agree

No I would rather not be photographed

Thank you for taking the time to complete this form. All the information shared on this form will be kept confidential and used solely to enhance your retreat experience. Our team is here to support you in any way we can. Please tick to confirm that you acknowledge our intentions here.

Guest Information Form

Guest Information Form Guest Information Form

Health Yourself

Guest Information Form