Healing Hope Retreat Registration Form
Please fill in the following application completely and be assured that all the information you give us will remain confidential and is being used solely for informational purposes. Please indicate your preferred dates of stay below. You may select any number of nights with a minimum of two nights to a maximum of four nights. We have found it beneficial if couples and/or families can stay for 3 nights but realize that schedules don’t always allow this amount of time. The cost for the retreat is just $250. We do ask for a $50 non-refundable deposit to be put down to reserve your stay. The rest can be paid at the time of your visit. We look forward to welcoming you and hope it will be a haven that allows you and your family to relax, reconnect and continue your healing journey. We will contact you as soon as we receive this to confirm the dates.
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Your First & Last Name *
Mailing Address *
Email *
Phone number *
Name of the person/organization who referred you to Healing Hope. *
Dates you would like to attend the Retreat *
List the names, ages and relationship of all who would be attending with you. (Note, it's a two bedroom apartment...1 queen, 2 twins and a couch are available). *
Please list 2 Emergency Contacts and their phone numbers, in case of emergency while you're staying with us. *
Who or what has helped you and your family since your child's death and in what ways? *
Describe any specific concerns you or your spouse/partner have relating to your grief process and your healing journey. *
Describe any specific concerns you may have relating to your surviving children and any concerns you've heard them express relating to their siblings death.
How would you describe your family's communication regarding the death of your child since their death? *
Does anyone in your family that is attending the retreat have any health problems or allergies that we should be aware of? If so, please explain.
Is anyone in your family currently taking any prescription medications? If so, please list the name of the medication and person taking it. Again, this is strictly confidential.
Tell us about your special interests or hobbies.
What are your expectations or hopes for your stay at Healing Hope? *
I/we understand and recognize that staying at Healing Hope is contingent on reception and approval of this registration as well as compliance with all conditions, qualifications, and restrictions designated by Healing Hope Ministries. *
Thank you again. We look forward to meeting you.  
Once again—ALL information is confidential. Healing Hope Ministries is a smoke-free and alcohol free facility. Thank you for your understanding. We will be in touch with you soon.

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