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!

First name

Last name

Confirm email

WhatsApp number

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Birthday

Place of birth

Your highest level of education

Medical Questions

Are you currently seeing a counselor, psychiatrist, or psychologist?

Yes

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?

Yes

If yes, please share which prescriptions, for what diagnosis, for how long and the results?

Are you currently under the care of a medical doctor?

Yes

Are you currently taking any medications?

Yes

If yes, please share

Experience

What previous personal development retreats/trainings/workshops have you attended?

Please share why you are interested in joining the SOHAM Programs.

What do you hope to take away from attending this workshop/retreat?

Final questions and comment

Is there any additional information you feel we will benefit from knowing before you attend this workshop/retreat?

Terms and Confidentiality Agreement

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

I agree to the terms & confidentiality agreement

Privacy Policy

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

I agree to the privacy policy

If you need an immediate support, please click here : CRISIS SUPPORT