Registration Form - Silent and Fasting Retreat

← Back

Thank you for your response. ✨

You will soon receive an email from the Portal Mãe Mirra team with the next steps.
1
2
3
4
5
6

Presentation

This form aims to get to know you better and understand your current physical, emotional, and mental health, your previous experiences, and your motivations for participating in the retreat.

This information is used to help us evaluate, together with you, which experience and meal plan are most suitable during your stay on the Portal.

We ask that you answer honestly and carefully. Some answers may require an individual conversation or evaluation/approval from a healthcare professional before participation is confirmed.

Your health information will be treated confidentially and used exclusively for the organization, security, and monitoring of your participation in the retreat.

1. ABOUT THE RETREAT

Which experience are you signing up for?(required)
Do you intend to stay for the entire period you initially chose?(required)
Have you visited the Mãe Mirra Portal before?(required)

2. PERSONAL DATA

Gender
Studies / training
Has there been a significant change in weight in the last 6 months?

3. CURRENT LIFE CONTEXT

Marital status / relationship status
Do you have children or other people under your care?

It may be important to let us know if you are going through situations such as bereavement, separation, job or residence change, childbirth, family conflict, illness of someone close, overload, personal crisis, or other significant transformation.

Are you going through any changes, crises, or significant events right now?(required)
Do you currently have a support network you can turn to after the retreat?(required)

4. PHYSICAL HEALTH

The questions in this section are part of our preliminary assessment. Selecting a condition does not automatically mean participation is impossible. Some situations may require individual discussion, adaptation of the experience, or evaluation by a healthcare professional.

How would you rate your physical health currently?(required)
Do you currently have, or have you ever received, a diagnosis of any relevant health condition?(required)
Have you ever undergone surgery, hospitalization, or received significant emergency care?(required)
Have you had a fever, infection, episode of dehydration, or other acute condition in the last 30 days?(required)

Conditions that require greater attention

Check everything that you currently have or that has occurred in the past that is relevant in your health history.

Health conditions

5. MEDICATIONS AND HEALTH MONITORING

For responsible monitoring, we need to know the medications currently being used. Do not interrupt, reduce, or modify prescribed medications to participate in the retreat without guidance from the responsible healthcare professional. The retreat team does not make changes to medical prescriptions.

Are you currently taking any medication?(required)
Do you use insulin or any other medication to control your blood sugar?(required)
Do you use medication to control blood pressure or diuretics?(required)
Do you use supplements, herbal remedies, or hormones regularly?(required)
Were you thinking about stopping, reducing, or modifying any medication in order to participate in the retreat?(required)

Important: Do not make changes to prescribed medications on your own. If a change is necessary, it should be discussed beforehand with the professional responsible for your care.

Are you currently under medical, psychological, psychiatric, or other healthcare professional care?(required)

6. Pregnancy, Postpartum Period, and Breastfeeding

Positive responses in this section will be evaluated individually before the dietary modality is defined.

Are you currently pregnant?
Are you currently breastfeeding?
Have you given birth in the last 12 months?

7. NUTRITION AND RELATIONSHIP WITH FOOD

What is your current diet like?(required)
Do you have any food allergies?(required)
Do you have any food intolerances or foods that you cannot eat?(required)
How do you currently view your relationship with food?(required)

8. EXPERIENCES WITH FASTING

Have you ever fasted before?(required)
Which sports have you participated in?
Have you ever experienced any of the following situations during a fast?
How is your daily hydration routine usually?(required)

9. ALCOHOL, NICOTINE AND OTHER SUBSTANCES

Do you currently consume alcohol?(required)
Do you use cigarettes, tobacco, vapes, or other forms of nicotine?(required)
Have you used cannabis or other psychoactive or recreational substances in the last 3 months?(required)
Have you ever had a relationship that you consider problematic or addictive involving alcohol, nicotine, medication, or other substances?(required)

Power plants and traditional medicines

Have you ever used power plants or traditional medicines, such as ayahuasca, rapé, or others?(required)
Have you experienced any difficult physical, emotional, or psychological reactions during or after these experiences?

10. EMOTIONAL AND MENTAL HEALTH

Silence, withdrawal, and dietary changes can also trigger emotional and mental aspects. These questions are intended for care and prior assessment.

How would you rate your emotional health right now?(required)
Have you ever undergone or are you currently undergoing psychotherapy?(required)
Have you ever had or are you currently having psychiatric treatment?(required)
Have you ever received a diagnosis related to mental health?(required)
Have you ever experienced significant events related to any of the situations below?
Have you experienced any significant emotional or psychiatric crises in the last 12 months?(required)
How is your sleep currently?(required)

11. MEDITATION, SILENCE AND SELF-AWARENESS PRACTICES

Do you have experience with meditation?(required)
Do you currently maintain any regular exercise routine?
Have you ever participated in a silent retreat?
Have you ever had a difficult physical, emotional, or psychological experience during meditation, retreat, silence, or another practice of introspection?(required)
Have you ever practiced or undergone other therapeutic, energetic, or self-care practices?

12. SELF-ANALYSIS AND SELF-ASSESSMENT

For each item, choose a number from 1 to 5 according to how you currently perceive yourself. 1 = requires a lot of attention. 5 = considered very developed or balanced.

13. MOTIVATION FOR THE RETREAT

14. BRIEF BIOGRAPHY

Tell us a little about yourself and your life journey. If it makes sense, you can talk about where you grew up, your family, education, work, important relationships, life-changing events, significant changes or crises, interests, spirituality, self-knowledge, what you enjoy doing, your service to the world, and the moment you are currently experiencing.

15. AVAILABILITY FOR THE EXPERIENCE

Do you understand that there will be extended periods of silence and reflection?(required)
Do you feel ready to observe silence as instructed by the retreat?(required)
Are you available to leave your electronic devices stored for the indicated period?(required)
Are you willing to follow the retreat's schedule and guidelines?(required)
Are you willing to remain in the space for the entire duration of the retreat? (required)
Do you commit to immediately informing the team of any significant physical, emotional, or mental changes, even if this means adapting or interrupting your fast?(required)

16. EMERGENCY CONTACT

Does this person know that you will be participating in a silent retreat and/or fasting activity?(required)
Can she be contacted by the team in a situation of need?(required)

17. PARTICIPATION AGREEMENTS

Read each statement carefully and check the boxes to indicate your agreement.

Participation agreements(required)

Reservation, Payment, Cancellation and Participation Agreements Policy

18. CONSENT FOR DATA PROCESSING

This form contains personal data and health-related information. This information will be used to evaluate your registration, organize the retreat, provide support during your stay, and address issues related to your care and safety.

19. How did you find out about the portal?

How did you hear about us?

Portal Communications

20. FREE SPACE

Right Menu Icon