Personal Writing Retreat Application Form - for Individuals in Recovery from Spiritual, Religious, or Cultic Abuse. 
APPLICATION
Email *
Name *
Address *
Phone
First Choice Retreat Dates  (Choose your dates from our Airbnb calendar) https://airbnb.com/h/dreamhavenofvt)
Second Choice Retreat Dates
How did you learn about Gerette Buglion and/or Writing to Reckon?
What do you hope to experience or achieve through attending a personal writing retreat here?
The cabin has a functional kitchen, including tea, coffee, spices and some staples. We offer the option of having the kitchen stocked with the food you want before you arrive (please note this below if interested and start a shopping list). You will be welcome to harvest from the garden in summer/fall months. Please share your thoughts and questions about how to best meet your dietary needs during your retreat.
If you want to have occasional meals with Gerette please share any dietary needs or preferences or questions.
Please share any specific needs or preferences for sleeping accommodations. The cabin is a separate dwelling in the backyard of our home. Are you comfortable sleeping alone? Would you like to bring a pet with you?
Our property is a 5 minute, approximately 3 mile drive or walk through a hilly area to the nearest store. Although having a car is not required, many people prefer to have one. Please share your thoughts, needs, and desires about transportation - to the cabin and while you are here. 
History of Coercive Experience
In this section, please offer the details that you are comfortable sharing at this time. You are welcome to be brief or go into as much detail as you wish. This form is essential when including writing consultations with Gerette in your retreat. Please know that all information will be held in strict confidence.
Name of Group/ Individual:
Leader’s Name (first name only is fine)
Date of beginning of involvement
Length of involvement
Date of leaving group
Describe how you met the group and any details about how and when you became fully committed and/or if you were born into the group, describe your family situation.
What were your reasons for joining, if you were not born into the group?
What helped you to leave?
List the names of significant members and leaders. Remember all of these questions are optional and only answer to the degree you are comfortable
What was your role in the group/situation? Describe the kinds of tasks or jobs you were responsible for.
How much and what kind of communication did you have with your family of origin when you were in the group/situation?
Have you had any contact with the group since you left? Please describe.
How do you think your involvement with the group/situation affects you today?
Why do you think a personal writing retreat is a good fit for you right now? What issues would you like to work on while here and what would you like to accomplish?
Have you ever been in therapy? If so, for how long and was it helpful? Please describe.
Are you currently working with a therapist? Please ask your therapist to share any concerns, goals, and potential triggers. Please also consider asking your therapist to sign a release statement to be able to speak with Gerette before and possibly during your retreat. 
Please share a little about your work with your therapist - what is/was most helpful, any issues or concerns you want us to know about.
Have you ever had psychological testing? Do you have any diagnoses?
What is your living situation presently?
Family Background As with all these questions, only answer to the degree you are comfortable doing so. 
Mother’s name and occupation
Father’s name and occupation
Siblings – please list names, ages, sex, and occupation
Are any of your family members in the group/situation?
Clear selection
Describe your family environment, identifying significant relationships and lack thereof within your family.
Describe any communication patterns within your family. Have there been any fights or estrangements that have impacted family members?
Is or was alcoholism, drug use, violence or sexual abuse present in your family? Please describe.
Describe any other significant relationships – spouse, close friends, children etc
Please share any cultural, religious or spiritual affiliations or beliefs you grew up with (if not described above).
If you entered the group as an adult, what was your religious background or spiritual perspective prior to entering the group? And what is it now??
Health Information
Do you have any health concerns that could impact your participation in a retreat?
Additional Data
Date of Birth
MM
/
DD
/
YYYY
Have you ever been arrested or convicted of a crime? Do you have any outstanding warrants?
Clear selection
Will you need any accommodations to access the property and the cabin? Please note that the cabin has a variety of  'quirks' that could be difficult for people who have physical limitations. Please read the full description of the cabin on the Airbnb link.
Do you have any allergies?
Have drugs or alcohol ever been a problem for you?
Clear selection
Are you currently using drugs or alcohol?
Clear selection
Is there anything else that you would like us to know?
Thank you for sharing! 
Gerette will respond to you within three days of receiving this completed form. In the meantime, please consider how much, or how little interaction with Gerette and/or Frederic you would like to included in your retreat. Options include:

Personalized Writing to Reckon and Feedback sessions 
Cult Recovery Education Consultations
Therapy sessions with Frederic 
Accompaniment in Nature (walking, hiking, canoeing, kayaking, cross country skiing or snowshoeing) or simply transportation and support/guidance to get the most out of the nature that surrounds 
Occasional meals cooked by and shared with Gerette* (she's a decent cook - nothing fancy, just nourishing).

FEES: 
The cost for the cabin is $125 per night.
Gerette and Frederic's time will be calculated at their normal billing rates and included in a Proposed Retreat Schedule. 
Meals prepared by Gerette will be billed at a reasonable rate to be determined, based on needs. 
*All retreats longer than four days include one optional dinner with Gerette and Frederic.  
So... think about all this and bring your ideas to the phone conversation or zoom, which is the next step is creating a plan for your personal retreat! 
Gerette's phone number is 802-498-8015 if you have burning questions before finishing this form. 
A copy of your responses will be emailed to .
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