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Awakening Retreat Intake Form
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Email
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Your email
Name
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Your answer
Mailing Address:
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Your answer
Phone Number:
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Your answer
Date of Birth:
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Your answer
Emergency Number and relationship to this person:
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Your answer
Who may we thank for the referral?
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Your answer
What do you need right now from this workshop? What are you hoping to achieve?
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Your answer
What is your marital status? If married, describe the relationship as best you can. If single, describe your situation
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Your answer
Please describe the dynamics in your family of origin and your relationship to your parents:
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Your answer
Anything significant you would like us to know about any of your siblings? Please list their names and ages.
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Your answer
If you have children, take a moment to write their names, ages and your relationship with them:
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Your answer
Medical background:
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Your answer
Do you have any physical or health limitations that the staff should be aware of?:
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Your answer
Do you have any food allergies or special dietary needs?
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Your answer
Are you currently under the care of a health professional for any reason - physical or mental? If yes, Please explain:
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Your answer
Do you have a history of heart problems, seizures, asthma, stress or anxiety attacks that have required medical intervention?
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Your answer
Are you taking prescription medication for any reason?
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Your answer
Do you have any addictions? If yes, please elaborate:
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Your answer
Were you physically, mentally or sexually abused as a child? If yes, please elaborate
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Your answer
Are you currently working with a therapist, psychiatrist or coach? And if yes, has this been helpful? Please elaborate:
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Your answer
Do you have a history or suicide attempts or making suicide plans or threatening suicide?
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Yes
No
Other:
Please describe if any overt signs of trauma that you experience (I.e. panic attacks, hyperventilation, withdrawing, disassociating, etc,)
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Your answer
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:
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Your answer
Covid 19 Liability waiver: The Awakening Retreat relies on the responsibility of it's participants to either be vaccinated or take a negative covid test prior to the workshop. The Awakening Retreat takes no responsibility for anyone who might G-d Forbid contract covid on or after a workshop. We will not be social distancing nor wearing masks.
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I Agree
I do not agree
In order to participate in this workshop, it is important that you agree to 100% confidentiality concerning other participants and any information you hear on the weekend. Please sign for this agreement:
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Your answer
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:
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Your answer
PAYMENT INFO (charged once approved)
Name on card
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Your answer
Full Billing Address
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Your answer
Credit card number
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Your answer
Expiration Month and Year (ex: 01/78)
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Your answer
cvv code:
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Your answer
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