top of page

S O H A M : The Liberation

APPLICATION FORM

May 9-14, 2025

Bali, Indonesia

YOUR APPLICATION DATA

We understand the potential sensitivity of some of the questions below. This can be a very vulnerable area of your life. This information is valuable for us to get to know and understand you better, which will enable us to make an informed decision about your participation in the program. We strive to provide you with the most appropriate and best possible care and support. Please answer honestly.
These questions and answers are strictly confidential and will only be reviewed by the therapist and facilitator Servane Surya.
Please confirm the accuracy of your information before submitting your application. Thank you very much!

​

Medical Questions
Are you currently seeing a counselor, psychiatrist, or psychologist?
Are you now being treated or have you ever been treated for any mental health conditions, including, for example (but not limited to) PTSD, psychosis (including drug-induced psychosis), chronic anxiety, bi-polar disorder, and sleeping disorders that required taking any form of medication and/or hospitalization?
Are you currently under the care of a medical doctor?
Are you currently taking any medications?
Experience
Final questions and comment
Terms and Confidentiality Agreement

Please take a moment to read our Terms and Confidentiality Agreement and indicate your acceptance by checking the box below.

Privacy Policy

Please make sure you have read and understand our Privacy Policy and indicate your acceptance by checking the box below.

bottom of page