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S O H A M : The Liberation

APPLICATION FORM

April 27-29, 2024

Ubud, Bali

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?
Have you ever been a patient in a mental health care facility?
Are you currently taking or have been prescribed psychiatric medications?
Are you currently under the care of a medical doctor?
Are you currently taking any medications?
Do you currently have any communicable diseases?
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.

Thank you! We’ll be in touch with you soon.

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