Wildlife and Wellness Retreat Survey

This form collects personal, health, and logistical information for safe and personalized support.

This field is for validation purposes and should be left unchanged.
Name(Required)
Preferred Name
Email(Required)

Health Overview

Age range

Where are you in your menopause journey?
Are you currently under the care of a physician for menopause-related care?

Do you have any current diagnoses we should be aware of? (Check all that apply)
Do you have any injuries, medical conditions, or physical limitations that may prevent you from participating in gentle movement, breathwork, or light mobility practices? Please describe.
Gentle Movement
Are you comfortable participating in gentle movement classes during this retreat?

Movement & Lifestyle

Exercise
What types of movement or exercise do you currently practice?
(Check all that apply)
Please describe what other exercise you engage in
What types of movement feel most supportive to you right now?
Is there any type of movement you are curious about or open to exploring during this retreat?
Relationship to Exercise
How would you describe your current relationship to exercise?

Symptom Survey

Symptoms
Which symptoms are currently most impactful for you? (Select as many as you need)
Please describe what other symptoms you experience
On a scale of 1–10, how regulated does your nervous system feel most days?
What feels hardest about this stage of life right now?

Emotional + Mental Wellbeing

Do you have any mental health concerns you’d like us to consider in supporting you?
What does this retreat represent for you?
Are you seeking more (select all that apply):
Please list anything additional that you are seeking during this retreat
Sensitive Discussions
How comfortable are you discussing hormones, sex, aging, and body changes in a group setting?

Food & Dietary Needs

We will have a private chef providing meals during the retreat.
Do you have any dietary restrictions, preferences, or allergies we should be aware of?