EI Registration Embodied Intimacy Registration form for November Women's Practice Intensive Name* First Last Email* Mobile*PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country ProfessionDate of Birth* DD MM YYYY GenderMaleFemaleOtherIf OtherPlease describeEmergency Contact Name*Emergency Contact Phone*How did you hear about this workshop* Through a friend Through Facebook Through this website Through the web Through promotional material Other If other, please give details Do you have experience or training in meditation, psychotherapy or tantra?* What is your primary reason for taking the workshop and what do you hope to get out it?* What do you find the most satisfying about your current relationship or sexual experiences?* What do you find the most challenging about your current relationship or sexual experiences?* Do you have a trauma history? If yes, was it sexual trauma?* Do you have a current or previous diagnosis or treatment of a mental illness (psychological or psychiatric)* Are you on any medication or consuming or using drugs, such as; amphetamines, diet pills, narcotics, cocaine, barbiturates, marijuana, heroine, etc.? If so, please give details such as, quantities and frequency of consumption?* Please upload an image of yourself for our private forum. I will crop it, so don't worry about size.TERMS & CONDITIONS* I have read the Terms & Conditions and agree to them By ticking this box below, you declare that you have carefully read the "Terms & Conditions" document on the "Embodied Intimacy" page: "http://lorellaricci.com/embodied-intimacy/" and agree to them.CommentsThis field is for validation purposes and should be left unchanged.