The following questionnaire is designed to help us accommodate you better. The information you give is strictly confidential. The results of this form will be viewed only by the abbot, Ajahn Punnadhammo.

About You
Your full name *
Email *
Town and Province or State
Date of Birth day month year
Gender Woman Man *
About Your Visit
Dates of Proposed Visit *
Reason for Visit Meditation Retreat
Work Retreat
How will you be travelling to Arrow River? Driving
About Your Practice
If you have previously done retreats here or elsewhere please list starting with the most recent.
where? how long?
where? how long?
where? how long?
where? how long?
Indicate your current practise, if any
About Your Mental and Physical Health
Have ever been diagnosed with a psychological condition? Yes No
If so, describe the diagnosis, treatment and dates.
Are you currently taking any medications for physical or psychological conditions? Yes No
If so, please list each medication and the condition it is being used to treat.
Do you have any physical challenges that might make it difficult to deal with the rustic conditions here? Yes No
If so, please describe
Describe any present circumstances which might be placing you under additional stress or make meditation difficult for you (e.g., recent loss of a loved one or job, substance abuse, fasting)
Anything to Add?
Please add any additional information or comments that you think might be useful

By submitting this form you are agreeing to the following statements:

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