IADC Screening Form
Thank you for your interest in attending the IADC 3 Day Retreat. Please complete the following information so we can review your information to determine if you would be a good candidate for the IADC session retreat experience.
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I saw a post on Instagram and didn't know you offered that. I follow your studio on eventbrite *
Name *
Address
Phone Number *
Date of Birth
Email *
Do you require any handicap accomodations  *
Please let us know if you have any food allergies, intolerances or need special food accomodations
Name of Deceased *
Date of Death *
Relationship to the Deceased *
Cause of Death *

Have you ever been or are you currently being treated for a psychological or psychiatric problem? Was any previous treatment EMDR? If so, describe your response to it?

 *

Have you ever experienced a traumatic event (abuse, natural disaster, accident, etc.)? Did you receive any mental health treatment?

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Please list any medications you are currently taking:

 *

Have you ever attempted suicide? Have you ever had suicidal thoughts?

 *

Have you experienced the full depth of your sadness related to the loss?

 *

Describe your available social supports/support system.

 *

Have you ever experienced an Out of Body Experience, Near Death Experience, or After-Death Communication? Briefly describe.

 *

Do you identify as religious, spiritual, agnostic, or atheistic?

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Is there anything else you’d like us to know?

 *

Would you need a payment plan or pay in full?

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Please rank the following items from 0 to 5 where: 
 0 = not at all 
1 = only a little 
2 = somewhat 
3 = considerably 
4 = to a great degree 
5 = completely or maximally
My loss is having an overall negative impact on my life.


Clear selection
I believe in an afterlife


Clear selection
The intensity of anger associated with my loss:


Clear selection
The intensity of guilt associated with my loss:


Clear selection
The intensity of sadness associated with my loss:


Clear selection
I have unwanted and distressing thoughts or images associated with my loss


Clear selection
I believe I can get on with life in spite of my loss:

Clear selection
I feel disconnected from the person who died:


Clear selection
I believe the person that died is still with me in an important way.

Clear selection
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