Personal Retreat Application Form

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Please Note: Before booking a Personal Retreat, you need to have completed at least 2 weeks teacher-led, Insight (Vipassana) or Zen meditation retreat in silence (either as two separate weeks or one continuous retreat of 14 days), not necessarily at Gaia House.

All Personal Retreat Application forms will be submitted to a Gaia House teacher for approval. Applications from people who do not have sufficient previous experience will be refused. If you have any questions before you apply, please call Reception: +44 (0)1626 333613

You can use the Personal Retreat Cost Calculator to calculate the cost of your proposed retreat.
Contact Details
First name*
Last name*
Email*
Phone*
Additional Phone
Address*
Address line 1 Address line 2 Town/City County Post code Country
Your Personal Information
The information you disclose in relation to your booking is used specifically in relation to the retreat you are applying for. This form is kept in both electronic and paper formats up to and throughout your stay. The information is used by teachers and other members of staff, as required as part of their duties. Once your retreat has been completed your electronic form will be deleted and your paper form shredded. Your application will also be deleted if your application is declined or subsequently cancelled. A record of your retreat dates will be held on our database.

If you do not interact with us for a period of five years, we will automatically make your record inactive on our database (suppress your details). You have the right to be removed from our system completely at your request. However, if you have made a booking within the last 12 months we are required to retain your details for two years for administrative purposes. Complete removal of information will result in the loss of all historic retreat data. For further information please read the Privacy Statement on our website.
Booking Details
Requested Retreat Dates
From:*
(the day you arrive)
To:*
(the day you leave)
Booking and Cancellation Conditions

Payment and Deposits:
- Retreats up to and including 3 nights: Please pay in full at the time of booking.
- Retreats of 4 nights or more: A non-refundable, non-transferable deposit of £100 will secure your place. Please pay the balance at least one month before the start date.
- If you have paid a deposit, an email will be sent to you to remind you to pay the outstanding balance.
- If you have not paid in full, one month before the start of your retreat, your place may be cancelled (with the loss of your deposit), and offered to someone on the waiting list.
Cancellation and Refunds:
- If you cancel more than 1 month before the start date of the retreat, the cancellation fee will be £100.
  - For low cost retreats such as Day Retreats, Dana Retreat, Work Retreat or Young Persons Retreat, the cancellation fee will be £10.
  - Please note that the Sponsor rate includes a non-refundable donation and is refunded at the Standard rate.
- If you cancel less than 1 month but more than 2 weeks before the start date, the cancellation fee will be £100 or half the cost of your retreat, whichever is greater.
- Extra nights cancelled more than 1 month before your arrival date will be refunded, less a £20 admin fee.
- Extra nights cancelled less than 1 month in advance will be charged in full.
- If you cancel less than 2 weeks before the start date, the cancellation fee will be the full amount paid.
Cancellation fees (less administration costs) are placed in the Financial Assistance and Bursaries Fund (FAB Fund).

Booking conditions may be subject to alteration. See: Booking and Cancellation.
I confirm:*
- I have read and agree to the Booking & Cancellation Conditions

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Practice Information

This 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 Period: Personal Retreats at Gaia House include a daily one-hour work period. Retreatants are allocated to a department according to the needs of the house. If you have any limitations which may affect your ability to carry out a work period, please give details:*
Retreat Experience: 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.
Retreat Intentions: What are your intentions regarding your meditation practice during your time on retreat? Which particular styles of meditation do you intend focusing on?*
Retreat Support: Personal 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?*
References: 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.

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Physical & Psychological History

Please note: A difficult psychological history and present will not necessarily prevent you from being accepted for this retreat. However, we do need to feel confident that you have the capacity and resources to be self-supporting in the silent retreat environment.

Please state 'no' or 'none' to any questions that don't apply.
Physical Health: Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing or walking practice?*
Mental Health Issues: 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).*
Have you ever attempted to take your own life? If yes, please indicate date(s).*
Mental Health Support: If you are involved with mental health services and have a Community Psychiatric Nurse, Psychiatrist or Support worker please provide their name and phone number.*
Stress: Describe any current circumstances which might be placing you under stress or may significantly affect your meditation practice:*
e.g. bereavement, redundancy, relationship breakdown etc.
Medication: Are you taking any medication for any physical or psychological condition? If yes, please give details of condition and medication.*
Is there any additional information you would like to convey to the teacher(s)?
Emergency Contact Details
Please give details of someone we can contact in the event of an emergency.
Emergency Contact Name*
Emergency Contact Phone Number*
Other Emergency Contact Information:
We very much look forward to welcoming you to Gaia House. It is important to us to be truly inclusive and welcome all people. We invite you to contact our Reception team if you want to tell us more about how we can welcome you: Email info@gaiahouse.co.uk or call 01626 333613.
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)
Send a copy of my application to myself
- to my email address
- to another email address
Email 2

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