Registration Form
1. Please fill out the following to register for your Glass House Intensive.
2. Upon receiving and approving your registration, you will be notified and directed to payment and travel arrangements.
3. When your full payment is verified and confirmed, your registration will be complete. Your registration is not guaranteed until your full payment has been received and confirmed.
Email address *
First and Last Name *
Your answer
Full Address *
Your answer
Phone *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
If you were referred to our program, can we contact your referral? If so, what is their contact info?
Your answer
Upcoming program that you are interested in? (choose all programs you are interested in) *
Required
Summarize why you are interested in coming to The Glass House. *
Your answer
Do you have a history of previous therapy, treatment centers or psychiatric hospitalization? If so, when and where?
Your answer
Are you currently seeing a therapist? If so, may we contact your therapist? If yes, please include phone number.
Your answer
Do you have any medical conditions or mental health diagnoses?
Your answer
Are you currently taking any medications? If so, please list them with the prescribed amount.
Your answer
Do you have a history of any suicidal thoughts or attempts?
Your answer
Did you experience any physical, emotional, or sexual abuse as a child or adult?
Your answer
Are you experiencing any self-medicating behaviors? (Food, alcohol, drugs, nicotine, sex, gambling, etc.)
Your answer
Do you have any physical limitations?
Your answer
Do you have any challenges with sleep? (Snore, sleepwalk, etc.)
Your answer
Are you a recovering alcoholic or drug addict? If so, how long have you been sober?
Your answer
Do you attend any 12-step programs? If so, which ones?
Your answer
Do you have a history of any eating disorders? *
Your answer
Do you have any food allergies or dietary needs?
Your answer
What is your married/partnership status? *
Do you have any children? If so, what are their ages?
Your answer
What are your general hopes for your time with us? *
Your answer
Any questions or additional information that you would like to offer?
Your answer
Cancellation Policy *
For all programs, if a cancellation is made 2 weeks (14 days) prior to your program start date, we will offer a full refund with a $700 processing fee. If you cancel after the 14-day window, there is no refund.
Required
Transfer Policy *
For all programs, if you wish to transfer to a different program, you may do so as long as it is before the 14-day cancellation window. There will be a $250 processing fee applied.
Required
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This form was created inside of Sirona Behavioral Health.