Awakening Retreat Intake Form

Retreat Registration

Step 1:

Complete the Retreat Registration Intake Form. It's imperative that all fields include the appropriate information.

Payment is REQUIRED to submit this form. Responses are not saved unless the payment has been processed.

Step 2:

Once approved by our Team, you will receive an email with remaining deposit information and next steps.

Step 3:

Get ready to RESET!

First Name

Last Name

Select an Address

Phone Number

Date of Birth (MM/DD/YYYY) required

Emergency Number and Relatioship to this person

Who may we thank for referral

What do you need right now from this workshop? What ae you hoping to achieve?

What is your marital status? If married, decribe the relationship as best you can. If single, describe your situation.

Please describe the dynamics in your family of origin and your relationship to your parents:

Anything significant you would like us to know about any of your siblings? Please list their names and ages.

If you have children, take a moment to write their names, ages and your relationship with them

Medical background

Do you have any physical or health limitations that the staff should be aware of?

Do you have any food allergies or special dietary needs?

Are you currently under the care of health professional for any reason - physical or mental? If yes, Please explain:

Do you have history of heart problems, seizures, asthma, stress or anxiety attacks that have required medical intervention

Are you taking prescription medication for any reason?

Do you have any addictions? If yes, please elaborate

Were you physically, mentally or sexually abused as a child? If yes, please elaborate

Are you currently working with a therapist, psychiatrist or coach? And if yes, has this been helpful? Please elaborate

Do you have a history or suicide attempts or making suicide plans or threatening suicide

Yes

Other

Please describe if any overt signs of trauma that you experience( i.e. pnic attacks, hyperventilation, withdrawing, disassociating, etc,)

Are you an observant Jew? While your religious observance will not be judged or criticized, we would like to have an idea of how you identify yourself

In order to participate in this workshop, it s important that you agree to 100% confidentiality concerning other participants and any information you hear on the weekend. Please sign for this agreement:

Liability Release: Awakening Within is a self help weekend of introspection and growth. It is not a substitute for professional mental healthcare and/or medication. Jewish Women Awaken/Awakening Retreat for men takes no responsibility should a serious problem arise during or after the weekend due to a previous mental condition that was not disclosed on this survey. Please sign your agreement:

DISCLAIMER: The information provided in this submission form is intended for internal use only. We assure you that the information shared will be kept confidential and will not be shared with any outside parties without explicit consent. By submitting this form, you agree to these terms.

Deposit required upon submission