Name and Contact Details
First Name *
Last Name *
County / State
Email Address *
Telephone Number *
Additional Telephone Number
Requested Retreat Dates (please note that Work Retreats run from Sunday to Sunday)
To avoid confusion, please give the full dates - for example: "January 12th 2013"
From * (the day you arrive)
To * (the day you leave)
Gaia House Booking and Cancellation Conditions
Deposit and Booking Fee:
Work Retreats must be paid for in full at the time of booking.
Cancellations and Refunds for confirmed Retreat places:
The Booking/ administration Fee is non-refundable.
The Deposit is refunded on satisfactory completion of your Work Retreat.
The Deposit is
NOT refunded if you cancel the booking or do not complete the Work Retreat.
Refunds have to be authorised by the Finance Department and can take up to 5 working days to be processed. Please note that cancellations can only be accepted from the named retreatant and not from third parties. Cancellations can be made by telephone or email.
All Cancellation Fees are placed in the Retreatant Support Fund.
I have read and agree to the Booking & Cancellation Conditions *
Year of Birth - e.g. "1954" *
Have you attended a retreat at Gaia House in the last 5 years? *
Gaia House offers a healthy, balanced vegetarian diet that may include eggs and dairy produce.
Vegan, Non-Diary, Non-Wheat, and Simple Diet options can be provided on request, when you register on arrival. (The Simple Diet option consists of a grain, steamed vegetables and plain pulses, egg or tofu, and is intended to meet nutritional needs while being as plain as possible.)
We are not able cater for other dietary needs which differ from these options.
Food Allergy/Sensitivity: • While cooks will endeavour to label any `problem’ ingredients, we cannot guarantee to do so. We cannot label the ingredients of soups or left-overs at tea-time. • Retreatants with a severe allergy should opt for the Simple Diet. • If there is a medical necessity, it may be possible for you to bring your own personal supplies at the discretion of the Kitchen Coordinators. Please phone before booking. • We are not able to store meat or fish on the premises.
If you have concerns that your needs cannot be met through this stated policy, then please get in touch with Reception before continuing with your booking on
ku.oc.esuohaiag or 01626 333613. null@ofni
I have read and accept the Food Policy and am aware of the dietary options. *
Mailing List for Retreat Programmes and Newsletters
Please add me to the Mailing List:
(Your details will not be shared with anyone.)
Yes Please No Thanks
The following information is strictly for the confidential use of teachers and staff on a need to know basis. Please answer these questions fully to enable the teachers to guide your retreat appropriately. Disclosure of any physical/psychological history will not necessarily prevent you from undertaking a retreat.
Please state "no" or "none" to any questions that don't apply.
Work retreats often involve work that is physically demanding. Work Retreatants are allocated to a department according to the needs of the house, and need to be able to work in any department. Please provide information on any limitations that may affect your capacity to work. Please be aware that some departments involve being able to do some heavy lifting. *
Please tell us of any skills you may have (for example, maintenance, gardening etc) *
Please provide information about any special needs you may have that we need to be aware of, for example, allergies or medical conditions: *
Gaia House is a silent retreat environment for sustained meditation practice. Retreatants need to be experienced and committed to both silence and solitude. Please list all silent meditation retreats you have undertaken, their duration and the teachers with whom you have practised. (If the list is extensive, please state this with a summary and list only your most recent retreats.): *
What are your intentions regarding your meditation practice during your time on retreat? Which particular styles of meditation do you intend focusing on? *
For Work Retreatants staying longer than 1 week: Interviews will be offered twice a week with one of the Gaia House Teachers, is this sufficient support for you? *
If your retreat is for longer than a month please send a reference (if possible) from a meditation teacher with whom you have previously practised or provide his/her contact details. *
Physical & Psychological History
Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing or walking practice? *
Have you ever been diagnosed with or experienced any significant mental health issues e.g. depression, eating disorders, anxiety, drug/alcohol abuse? If yes, please give details of condition(s) and date(s). *
Are you taking any medication for any physical or psychological condition? If yes, please give details of condition and medication. *
Have you ever attempted to take your own life? If yes, please indicate date(s) *
If you are involved with mental health services and have a Community Psychiatric Nurse, Psychiatrist or Support worker please provide their name and telephone number. *
Describe any present circumstances which might be placing you under additional stress or may significantly affect your meditation practice (e.g. bereavement, redundancy, relationship breakdown etc) *
Emergency Contact Details
Name & Telephone Number(s) of someone we can contact in case of emergency: *
I agree to take full responsibility for myself during this retreat. I understand that all retreatants need to observe the practice guidelines and that retreats at Gaia House are undertaken and continued with the agreement of the teacher.
Retreatant Signature (please type in your full name in lieu of a signature)
* = required