Application / Intake Form

Waiting List – Distance Healing Journey

Open Dates

Retreat Guru is the online booking agent for Paititi Distance Healing.

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Contribution

Select a price
$500.00 – Full Program (Nutritional Coaching, Dream Exploration, One-on-One Coaching & Energetic Healing)
$200.00 – A la Carte: Nutritional Coaching Only
$200.00 – A la Carte: Spiritual Coaching Through Dream Exploration Only
$100.00 – A la Carte: One Hour One-on-One Transformational CoachingOne-on-One Transformational Coaching Only

You will not be billed for the program at this time of submitting your application. Please note that there is a $25 application fee which is required in order to submit your application. This fee will be added to your final contribution should you decide to initiate the program after the orientation call (within 1 year of the date of submitting this application).

Optional Items

Participant Info

feet/inches
Pounds
Full Name, relationship, phone #, & email

Medical Background

Enter "none" if you have no issues
stool analysis, blood & urine chemistries, hair analysis, etc.
If yes, specify name, dosage & duration of use? If no please state this.
share the name of medication, when stopped, & how the transition process went (or is going)
list all procedures, complications (if any), outcomes, & dates
if yes, please specify (pesticides, radioactivity, solvents, fireman, mining, etc )
1 very low low - 10 very high

What types of therapy have you tried for your condition past or present? (explain what you did & it’s effectiveness)

provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness
provide details on what you did & it’s effectiveness

Men's Health

Women's Health

specify start & end dates of all times you have taken birth control, type of birth control & any side effects
heavier, large clots, scanty, etc

Heath Habits:

walk, run, job, jump rope, weight lift, swim, yoga, etc

Nutrition & Diet:

good habits, bad habits, if you listed other above please expain here
If none, please state this

Background & Goals:

Confirm and Submit:

Read Client Engagement Package Here This package must be signed an returned after your orientation call.

Payment

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Retreat Guru is the online booking agent for Paititi Distance Healing.
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Charges will appear on your bill as "RG *PaititiDista"