Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1Personal Details2Service & Timing3Experience & Preferences4Planning & Final DetailsThis form is for clients seeking ongoing, high-touch wellness travel planning and longevity-led stays. Share the details below and we’ll come back with the clearest next steps. Name *Email *Phone *Preferred contact method *WhatsAppEmailPhone callCity of residence *Emergency contact number *NextWhich service are you looking for? *Wellness concierge (ongoing planning + bookings across the year)Longevity stay (single stay with measurable wellness outcomes)Longevity stay onlyBoth (concierge + longevity stays)What best describes you *High-performing professionalFounder / executiveFamily decision-makerHR / EA / office manager booking for leadershipOtherCould you please specify?How soon are you looking to begin? *Immediately (within 2–4 weeks)1–3 months3–6 monthsPlanning for later this yearTravel frequency *One key wellness trip per year2–3 wellness trips per yearQuarterly resetsNot sure yetTypical stay length you prefer *2–3 nights4–6 nights7–10 nights10+ nightsDeparture city / airport *Regions you’re open to *Middle EastEast AfricaSouthern AfricaIndian Ocean islandsEuropeOpen to recommendationsNextWhat are you optimizing for? *Nervous system reset / burnout recoverySleep restorationSustainable weight managementStrength + mobility foundationEnergy optimization / fatigue recoveryLongevity & regenerative protocolsWomen’s wellness / hormone supportExecutive performance + recovery rhythmPostnatal recoveryOther (share below)If you chose “Other”, specifyWhat should feel different after this stay?Preferred accommodation style *5-star hotel / resortPrivate villa with servicesLuxury lodgeI’m open if it’s exceptionalYour ideal environment *Quiet + highly privateNature / greeneryBeach accessCooler climate / mountainsAdults-onlyMinimal moving / one baseOpen to recommendationsYour preferred pace *Very calm (minimal activities)Balanced (wellness + light experiences)Active (structured daily sessions)Any medical conditions, injuries, or mobility limitations we should plan around? If yes, share what matters for planningFood preferences *No restrictionsHalalVegetarianVeganGluten-freeDairy-freeAllergies (add below)AllergiesAny cultural or personal considerations we should respect?NextInvestment range (per person, per stay) *Under $5,500$5,500–$9,000$9,000–$15,000$15,000–$21,000$21,000+For wellness concierge, what level of ongoing support do you want? *Light concierge (planning + bookings as needed)Full concierge (ongoing planning + priority access + complete coordination)Not sure — recommend what fitsDecision status *Exploring optionsReady to book soonNeed a concept/proposal to approve internallyI’m comparing providersWho signs off the decision? *MeMe + partnerA group decisionCompany decision (HR/EA/Leadership)Anything else you want us to know?Would you like to receive occasional updates from Nivana (retreat releases, destination insights and wellness travel notes)?YesNoConsent *I agree that Nivana may use my details to respond to this inquiry and curate recommendations for this request.Custom Captcha * = Phone you’re matters Submit
