Name and Contact Details
First Name *
Last Name *
Address *
Town / City *
County / State
Post Code
Country *
Email*
Phone*
Additional Phone
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.
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.Booking and Cancellation .
I have read and agree to the Booking & Cancellation Conditions *
Personal Details
This helps us to arrange appropriate accommodation.
Gender *
Female Male Another gender identity
Additional information (optional)
You are welcome to provide additional information if you would like to. Our Retreat Manager will contact you via email to discuss your accommodation needs. Any information you provide is confidential and will only be used in support of your retreat.
Do you have specific needs relating to a disability or health condition?
No Yes
Additional information (optional)
You are welcome to provide additional information if you would like to. Our Retreat Manager will contact you via email to discuss your needs. Any information you provide is confidential and will only be used in support of your retreat.
Date of Birth *
Have you attended a retreat at Gaia House in the last 5 years? *
No Yes
FOOD POLICY
Gaia House offers a healthy, balanced vegetarian diet that may include eggs and dairy produce.
Vegan, dairy-free and wheat/gluten-free options can be requested when you register on arrival.
We also offer a ‘Simple Diet’ consisting of a gluten-free wholegrain, steamed vegetables and plain pulses, egg or tofu. This diet is intended to meet nutritional needs whilst being as plain as possible. You can request the simple diet when you register on arrival.
If none of the above options meet your dietary needs, or you have a medical need for a different diet, please contact our Retreat Manager, Susanne O’Brien, on retreatmanager@null gaiahouse.co.uk before booking your retreat.
Food Allergy/Sensitivity:
We always label dishes containing any allergens you have told us about.
Whilst on retreat, please speak to a member of the Gaia House team for more information on allergens in our dishes.
I have read the Food Policy and am aware of the dietary options. *
Keep in touch with Gaia House:
Gaia House E-News - sent occasionally by email.
Yes Please No Thanks
Retreat Programme and Newsletter - sent once a year by post, to recent retreatants
Yes Please No Thanks
Your details will not be shared with anyone.
Practice Information
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.
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:*
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? *
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? *
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 phone number. *
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) *
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@null 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*
* = required
