Escape To Bliss Questionnaire

Bliss Retreat-Participant Questionnaire

Your journey begins here.

Thank you for joining us for the Bliss Retreat. We’d love to get to know you before we gather in Bali so we can create the most powerful and personalized experience for you.

Please answer honestly and from the heart—there are no wrong answers.

First name

Preferred Name/Nickname

Last name

Birthday

Day

Month

Year

Phone

Your Current Journey

1. What inspired you to come to the Bliss Retreat?

2. What are the top 3 challenges you're currently facing (emotionally, physically, spiritually, or relationally)?

3. Are there any limiting beliefs, patterns, or blocks you’re ready to release?

4. What would bliss look like or feel like for you at the end of this retreat?

Healing & Personal Development

5.Have you done any previous healing or personal growth work (e.g., therapy, breathwork, coaching, spiritual practice)?

6. Are there any particular healing modalities or practices you are drawn to or curious about?

7.How comfortable do you feel opening up in a group setting? (1 = very uncomfortable, 10 = totally at ease)

8.What kind of support would feel most nourishing to you during the retreat? (e.g., quiet reflection time, 1:1 support, group sharing, physical practices)

Body, Mind, Soul

9. How is your physical health currently? Any limitations or conditions we should be aware of?

10. Do you have any specific dietary needs or allergies?

11. Is there anything we should know about your mental/emotional wellbeing to support you fully?

The Deep Dive – Get Real, Get Free

12. When you’re alone with your thoughts… what do you secretly wish would change in your life—but feel unsure how to change it?

13.If your body could speak, what would it beg you to stop doing… and what would it ask you to start doing?

14. What emotion do you avoid most—and why do you think it scares you?

15. Are there parts of yourself you hide from others (or even from yourself)? What are they?

16. What’s one memory that still feels like it owns a piece of you?

17. What have you been tolerating in your life that you know is costing you your peace?

18. What belief do you carry about yourself that you know is outdated—but still sneaks in when you’re vulnerable?

19. What would it mean for you to truly feel safe—in your body, your relationships, and your future?

20. When was the last time you felt fully seen and understood? What made that moment so powerful?

21. If you could walk away from the retreat with one life-changing shift… what would it be?