Application: Women Who Want More 
The information collected in this form is confidential and can only be accessed by Ilana and Tammy. By completing and submitting this form, I'm giving Ilana Singer Siegal and Tammy Valicenti permission to access this information. Information collected in this form is used solely for the purpose of applying for this retreat and will not be shared or used for any other purpose.
TC Berkshires, LLC
Rates (Single & Double occupancy) $2900-$3900
Work-study Rates available upon request
Name *
Email *
Address: Street, town & zip *
Phone number *
DOB: *
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Occupation *
How did you hear about the retreat? *
Accommodation Preference *
 What are your goals/hopes/expectations for this retreat?
 *
What, if any, are your concerns or fears?
What do you like about yourself/what are some of your strengths? *
What do you not like about yourself/what do you want to change/improve? *
Hope scale *
Very hopeless
Very hopefull
Anxiety scale *
Never
Constant
Depression scale *
Never
Constant
Have you ever been hospitalized.? If yes, for what and when. *
Have you done EMDR before? If yes, how was your experience? *
Are you currently working with a therapist? *
If yes to the previous question, may we contact them once you've signed a release? *
Relationship status *
Do you feel that your primary relationship is affecting your current functioning and if yes, how? *
Who do you live with? *
Who are your primary supports? *
How often do you consume alcohol? *
How often do you use other drugs? *
Do you or those around you have concerns about your drug or alcohol use? *
Do you have children? *
Do you consider yourself to be spiritual or religious? *
Please list any and all medications: *
Is there anything you want us to know about your current emotional, mental or physical health?
What do you like to do for fun? To take care of yourself? *
Do you have a regular yoga or meditation practice? *
Anything else you'd like us to know about you for the purposes of this application? Any questions?
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