Hiraya Wellness Retreat Survey Application

Thank you for considering the Hiraya Wellness Retreat.

Kindly answer all the questions - yes there are a lot of questions, but the questions are important for us to be able to understand how we can help you.

Please remember that this is not just a form, but an application. Not every submission will guarantee a spot in our program.

Our dedicated team thoroughly reviews each application, ensuring we can provide a transformative and beneficial retreat experience for all attendees.

The information you share will be treated with the utmost confidentiality and is solely to help us understand your unique needs and circumstances.

Once your application is reviewed, you will be contacted via email/ text message or Whatsapp with the next steps. We appreciate your understanding and patience throughout this process.

Your journey towards holistic mental wellness could indeed begin right here with Hiraya Wellness Retreat.

Name - as shown in passport

Phone

Date of birth

Month

Day

Year

What is your marital status?

What is your profession?

Do you have children? If Yes indicate how many, if none simply indicate.

Where would you like to receive a notification regarding your Hiraya Retreat application?

Before we proceed with further questions, please note and confirm that you have read the following policies below: 1) Retreat Rebooking Policy 2) Confidentiality & Non-Disclosure Policy 3) Right of Refusal Service Policy

Please confirm that you have read and noted the Retreat Rebooking Policy, Confidentiality & Non-Disclosure Policy, Right of Refusal Service Policy. Answering - Yes confirms that you understand and confirm to do so.

Yes

No (If not yet, this will be a required step in applying for our retreat)

Are you aware of the Hiraya Mental Wellness Retreat Prices? 4-Day Mental Wellness Nature Retreat: Special Soft Launch Rate: from USD $4,800 to now only $3,333! (₱200,000 pesos) - inquire for special local Filipino rate. To see details of the pricing ple

Yes

Target Date to join a Hiraya 4-day Retreat (We only have 6 retreats per year - max of 8 people)

What motivated you to sign up for this mental wellness retreat?

Seeking stress relief

Personal growth and self-discovery

Coping with a recent life event (e.g. loss of job, divorce, etc.)

Managing a mental health condition

Other

Have you ever attended a mental wellness retreat before? If so, please describe your experience.

Yes, it was a positive experience

Yes, it was a negative experience

Yes, it was a neutral experience

No, this is my first time attending a mental wellness retreat

If your answer to the above question is YES what is the kind of retreat have you attended? Please specify...

On a scale of 1 to 10, how stressed or overwhelmed do you feel currently?

What are your expectations from this retreat?

Learning new coping strategies

Connecting with others who have similar experiences

Gaining insights about oneself

Taking a break from daily routine and responsibilities

Other

Are there any activities or therapies that you are not comfortable participating in? (Yes - please specify, No - just indicate 'No'.)

Are you currently under the care of a mental health professional?

How often do you experience symptoms of anxiety or panic attacks?

Have you ever been diagnosed with a mental health condition? (Yes - please specify. No - just indicate 'No'.)

How comfortable are you discussing mental health issues with others?

How much sleep do you typically get per night?

Have you ever participated in mindfulness or meditation practices?

What specific goals do you hope to achieve by attending this retreat? (Please specify)

How do you usually cope with stress or negative emotions? (Please specify)

What activities or exercises have you found helpful in managing stress or anxiety? (Please specify)

How often do you engage in physical exercise?

Have you experienced any physical injuries or limitations that could affect your participation in physical activities during the retreat? (Yes - please specify. No - just indicate 'No'.)

Do you have any physical, medical or dietary requirements that we need to be aware of? (Yes - please specify. No - just indicate 'No'.)

Is there anything else you would like us to know or be aware of to ensure you have a positive experience at the retreat? (Yes - please specify. No - just indicate 'No'.)

Do you have any chronic health conditions? (Yes - please specify. No - just indicate 'No'.)

Have you ever undergone surgery or a major medical procedure? (Yes - please specify. No - just indicate 'No'.)

Do you have any allergies? (Yes - please specify. No - just indicate 'No'.)

Are you currently taking any medication or supplements? (Yes - please specify. No - just indicate 'No'.)

Have you ever had a severe reaction to any medication or supplement? (Yes - please specify. No - just indicate 'No'.)

Do you have any dietary restrictions (e.g. vegetarian, vegan, gluten-free, etc.)? (Yes - please specify. No - just indicate 'No'.)

Are there any foods or ingredients that you are allergic or intolerant to? (Yes - please specify. No - just indicate 'No'.)

Are you comfortable trying new foods?

Yes

Other

What are your favorite types of foods? (Please specify)

Do you have any specific food preferences or dislikes? (Please specify)

Have you ever visited before this/these places?

Are there any specific amenities or features you would like your accommodation to have? (Yes - please specify. No - just indicate 'No'.)

Do you have any specific questions or concerns about the retreat that you would like addressed before your arrival? (Please specify)

If yes, how did you learn about them?

Have you ever tried any of the medicines or therapies listed above?

What were your reasons for trying alternative medicines or therapies? (If not yet tried, simply indicate)

Did you have a positive experience?

If No, what caused the experience to be negative? (Please specify)

Are you aware of the potential risks and benefits associated with using alternative medicines or therapies? (Select one)

Yes, I am well-informed

Somewhat, but I would like to learn more

No, I am not informed

Other

Have you ever discussed the use of these alternative medicines or therapies with a healthcare professional? (Select one)

If yes, what was their response? (Yes - Please specify. No - simply indicate 'No'.)

If you have not tried any of the alternative medicines or therapies listed above, would you consider trying them in the future?

Yes

Maybe

Other

If you answered "maybe" what factors would influence your decision? (Please specify)

Would you be willing to try any of the alternative medicines or therapies listed above with guidance from an experienced facilitator?

Yes

Maybe

If you answered "maybe" what factors would influence your decision? (Please specify)

Are there any concerns or reservations you have about using alternative medicines or therapies for self-improvement or therapeutic purposes? (Please Specify)

Do you have any additional comments or thoughts on the use of alternative medicines or therapies for mental health and personal growth?

Acknowledgment and Agreement

By submitting this form, I hereby confirm that all the information I have provided is accurate and truthful to the best of my knowledge. I understand that this information will be used by the Hiraya Wellness Retreat team, including its medical professionals, to guide and assist me during the program.

I also acknowledge that the retreat may include holistic and all-natural alternative therapeutic approaches under the supervision of experienced facilitators and licensed physicians.I voluntarily choose to participate in these activities and confirm that I am open to exploring these methods as part of my personal wellness journey.

I fully understand and accept the risks and benefits associated with my participation and agree to take full responsibility for my personal health and well-being during the retreat.

Single choice

Yes, I agree and acknowledge.

No, I do not agree and acknowledge, and I do not wish to participate in the retreat.