Couples Retreat Application:
An exclusive experience with Dr. Ellen Langer,
Michelle Cameron Coulter & Randy Lennon
March 13–17, 2026 | Puerto Vallarta, Mexico

Full Name *

Preferred Contact Email *

Phone *

Partner's Name *

Partner's Email *

Are you currently in a committed romantic relationship?

Yes

NOTE: This retreat is intentionally designed for couples in a committed romantic partnership, focused on deepening their connection.

How would you describe your relationship?

Married

Engaged

Long-term partnership

Other - please specify below

If "other" for above question please expand here

What drew you to this retreat experience with Dr Langer?

What are you hoping to gain, shift or explore together during this retreat?

On a scale from 1-10 how would you rate your current relationship health?

On a scale from 1 to 10, where would you place yourselves on your self-awareness or personal growth journey?

In a few sentences, describe how each of you approaches personal development and mindfulness:

Are you available to travel to Puerto Vallarta, Mexico from March 13-17, 2026?

Yes

Not sure yet

Are you in a financial position to invest $25,000 USD for this all-inclusive couples retreat (not including airfare)?

Yes, we’re ready

Not yet, but interested in future offerings

Future interest in any or all of the following:

Future Couples Retreats

Online programs or workshops

Subscribing to Dr. Ellen’s private insights & content

Future Singles Retreats

One day retreats and other workshops with Dr Ellen, Michelle Cameron Coulter and/or Randy Lennon

All of the above

Is there anything else you'd like us to know about you as a couple?

Where did you hear about the Retreat?

I agree to receive important updates about this retreat and related services (e.g., confirmations, reminders).

I'd also love to receive exclusive content, future event invitations, and special offers from Dr. Ellen and the team. I understand I can unsubscribe at any time.