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Fasting FormWellnessFarm2022-06-20T13:58:42+02:00

Fasting Detox Expression of Interest & Application

FASTING RETREAT EXPRESSION OF INTEREST If you are interested in participating in the upcoming Fasting Retreat, please complete this form. The form is a general health intake form, which is a prerequisite for all fasting participants (even if you have fasted with us before). Once reviewed, you will receive an email to the address you provide below which will contain an invitation to a Zoom/Skype chat to discuss your unique needs.

"*" indicates required fields

1Biographical Data
2Emergency Contact Information
3General Information
4Fasting Brackground Information
5Health Status
6Physical Health
7Food Notes
8Drug Notes
9Psychological
10Submit
Enter the data requested below.
Name*
Email*
Address*
Please provide an emergency contact below.
Name*
Enter the name of someone you trust who we can contact in case of an emergency.
What is your relationship to/with this person?
Please provide the best phone number for your emergency contact person.
Please answer the questions below.
Your Birthdate*
When were you born?
What do you do for a living?
Please provide information regarding your experience with fasting.
Have you fasted before? (drinking clear liquids only)*
How many days long did you fast for?
What did you consume while fasting? (water, juice, etc.)
Have you participated at a fasting retreat with International Wellness Farm?*
Please select the boxes for any condition that applies to you either now or in the past.
Diabetes or high blood sugar*
Please specify – Type 1 or Type 2*
Arthritis
Select only if applicable
Asthma
Select only if applicable
Bone or Joint Problem
Select only if applicable
Bowel Disorder (crohn's, colitis, etc.)
Select only if applicable
Cancer
Select only if applicable
Candida Albicans (yeast infection)
Select only if applicable
Cardio-vascular disease, Heartattack or other heart condition
Select only if applicable
Dizziness or Loss of Balance or Consciousness
Select only if applicable
Epilepsy or seizure disorder
Select only if applicable
Hypertension/high blood pressure
Select only if applicable
Hypoglycemia (low blood sugar)
Select only if applicable
Immune system imbalance (Lupus, Epstein-Barr, HIV, etc.)
Select only if applicable
Liver Disease (Hepatitis, etc.)
Select only if applicable
Nervous system disease (M.S., Parkinson's, etc.)
Select only if applicable
Are you Pregnant or do you think you may be?*
Prescription drugs
Select only if applicable
Thyroid problems
Select only if applicable
Urinary tract disorder (kidney, bladder)
Select only if applicable
Weight loss or gain
Select only if applicable
Please answer the following questions.
Please answer the following questions.
Are you currently using any of the following?
Select all that apply
(Example - Caffeine: 2 cups of coffee per day or Alcohol: 1 glass of red wine with dinner 2-3 times per week ...etc.)
Please answer the following questions regarding your psychological health.
Do you have any food or animal allergies?*
Consent*
By checking you confirm that you read and accept our Privacy Policy

Sarah

10 DAY JUICE FAST

This was the best detox retreat I went on and it was also much more then that (highly recommended it) I did this for health and spiritual reasons. I chose this offering as it was in Sweden and I wanted to go there. It offered to teach you about alternative ways to support your health. I did a 10 day fast. I learned loads about diet and nutrition. I made good friends. Feel emotionally and spiritually better.

Maša Slovenia

THERAPEUTIC ART RETREAT

The Art Retreat was an amazing experience. We got the chance to try out out various techniques and explore our creative sides. The art classes were carefully prepared by Helena and I was able to discover techniques I never dreamed off. The whole retreat was a unique opportunity to completely relax and be myself without any pressures of the everyday life

Rita

10 DAY JUICE FAST

I wanted to detox my digestive system, and destress. I chose this retreat as it offered isolation. I lost 10lb, my digestive system seems to be working better. I have a clear way to keep this continuing I think I have destressed and feel happy to get on with my life. This facility will give them the opportunity to reset their mind, body, emotional and soul if they wish. A wonderful place with amazing staff that make you feel like part of their family.

About The International Wellness Farm

Transformational Juice Fasting and Detox Retreats designed to awaken your internal compass.

Individual and group kambo ceremonies, co-creative music experiences aligned to the primacy of our own heart-opening felt experience aligned to find a way through to the next iteration of You.

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