Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone number

(###)

###

####

Primary reason for attending immber

Pain reduction

Self care

Improved sleep

Stress reduction

Improved posture

Medical history (please tick all that apply)

High blood pressure

low blood pressure

Hip pain

Headaches

Pregnancy

Back pain

Neck pain

Epilepsy

Anxiety / Depression / Mental illness

Shoulder pain

Asthmer

Scoliosis

Checkbox

Option 1

Option 2

Agreement

The above information is complete and correct. I understand that the information will be regarded as confidential. I will take responsibility to alert Rebecca if anything feels painful or unusual during the immersion. I give permission for Rebecca to seek medical attention for myself if necessary. Unless necessary I will turn off my mobile phone throughout the immersion. This immersion has been designed to support guests in their personal development. It is my hope that the 3 days significantly positively impacts guests abilities to identify and create or enhance personal goals. The immersion is a comprehensive process that can impact a number of areas; however, if the guest wishes to incorporate learning into these areas it is entirely up to her. This immersion is not counselling, therapy or a related discipline and will not be carried out or treated as such. As part of this relationship, by ticking the box below it indicates you understand and agree that you are fully responsible for your physical, mental and emotional well-being, including choices and decisions made as a result of engaging in this process. Should I believe that, at any given time during the Immersion process, you may require additional support, I will recommend you consult a professional and can refer you in this regard. Complete Balance is insured for accidents while on the property. Please know that swimming and leaving the property is done at your own risk.

By ticking this box I acknowledge I have read and understood the above agreement.