Awakening Retreat Interest Form

AWAKENING Retreat Interest Form:

Fill out the information below to express interest in the retreat. You will be contacted with additional details regarding registration information. Please note that completion of this form does not register you for the retreat.
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Are you a current or former client of Christina Alston, LPC?
Are you currently seeing a mental health professional? (Check all that apply)

Other
Previous psychiatric treatment (check all that apply)

Other
Describe your spiritual/religious beliefs:
What sparked your interest in this retreat?
What do you hope to gain as a result of this retreat?
Questions or Comments:
Should be Empty:

AWAKENING Retreat Interest Form: