Booking Form Booking Form Availability* 21st-25th Sept 2026 - Belvoir Lodge Retreat - Leicestershire 15th-21st June 2026- NLP Practitioner Training - London Room TypeOccupancy is subject to availability at time of booking. No Room - NLP Training Only Twin Sharing - Solo Traveller Twin Sharing - Friends Couples Sharing Room Single Room - Shared Bathroom Single Suite - Ensuite Bathroom Master Suite - Private Lounge, Library, Clockroom, Walk in Wardrobe and Ensuite Bathroom Title*MrMrsMissMsDrProfSirDameLordLadyFirst Name*Last Name*Email* Mobile Number*How did you hear about us?*Pre Screening*Platinum Healing is NOT a medical, mental health or rehab facility. If any of the below applies to you, please provide further details or contact us to see if the retreat is suitable. We cannot support any persons with current alcohol or drug addictions or severe mental or physical health conditions. Pregnant or Nursing Mother Insulin Dependent Diabetes Peptic Ulsers History of Heart Issues/Disease Alcoholism Rehab (within the past 2 year period) Anorexia or underweight Mental Illness Psychiatric Care Drug Abuse Recent Operations (within the past 2 years) Epilepsy Seizures NONE OF THE ABOVE APPLIES TO ME If you have ticked any of the above, please provide full details below.Allergies*We are unable to guarentee that our venues kitchens are free from nut or other allergens that result in anaphylactic shock. We also produce nut milks and use celery in our juices. I DO NOT have allergies that result in anaphylactic shock Please list ALL known allergies (if any)Preferred Program* Juice Detox Meals (Thailand only) I will be:* coming alone with a friend (please provide full name and relationship below) with a family member (please provide full name and relation below) with my partner (please provide full name below) in a group (please provide full names of your entire party below) Who is joining you?Names and relationship to the people I am coming to the retreat with (if applicable). PLEASE NOTE: All individuals joining you MUST complete a separate booking form and health assessment. Gender*MaleFemaleOtherDate of Birth* DD slash MM slash YYYY Have you ever been on a detox retreat before?*YesNONo - but I have been on a wellness or yoga retreat beforeIf yes please give the name and locationWhat made you choose Platinum Healing over other Retreats?*Emergency Contact Full Name*Emergency Contact Number*I agree these details have been authorised by the person stated and that they have agreed they can be contacted at any time in the event of any emergency*YesI confirm that I have read and agree to the Terms and Conditions and that;*https://www.platinum-healing.com/welcome/terms-and-conditions/ Select All The information I have provided is, to the best of my knowledge true and accurate. I will inform Platinum Healing of any changes prior to retreat start and throughout the retreat I do not have any known allergies that result in anaphylactic shock There is a set juice detox menu included in the price of the retreat. Any changes may incur a surcharge. My GP/Medical Practitioner and I remain responsible for my own health throughout the retreat and beyond. Platinum Healing is a retreat for 'Self Healing' NOT a medical, mental health, addiction or drug/alcohol rehab facility. I assume full responsibility for my health and obtaining clearance from my medical practitioner to attend a retreat or treatment I understand that the use of alcohol and recreational drugs are strictly prohibited on the retreat I have agreed to receive all integrated therapies of my own free will and without any coercion or undue influence. I understand that my booking may be cancelled if I fail to inform Platinum Healing of any known mental or physical illness I understand the package that I have chosen and what it involves and includes I agree to all booking and cancellation terms I agree to the full disclaimer and waiver of liability I hereby acknowledge that;* I have read and understood Platinum Healing's privacy policy and I am happy for Platinum Healing to contact me and for my personal data to be stored. Signature*Please type your full name below. Date of Signature* MM slash DD slash YYYY Δ
