APPLICATION FOR ADMITTANCE INTO RETREAT
GENERAL INFORMATION
Name
First Name
Last Name
Phone Number
Please enter the number you would like us to use to contact you.
Email
Please use the email you would like for us to use to contact you.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
EMPLOYER INFORMATION
EMPLOYER:
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
POSITION HELD:
YEARS OF EXPERIENCE:
DUTIES:
TRAUMATIC EXPERIENCES AT WORK:
Type a question
HAVE YOU EVER BEEN AT WORK:
SUSPENDED:
YES
NO
DETAILS:
PLACED ON A PIP:
YES
NO
DETAILS:
WRITTEN REPRIMAND:
IS YOUR JOB AT RISK NOW:
YES
NO
DETAILS:
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MENTAL HEALTH INFORMATION
HAVE YOU EVER RECEIVED MENTAL HEALTH COUNSELING:
YES
NO
CLINICIAN NAME :
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
DATES OF TREATMENT:
HAVE YOU EVER BEEN A RESIDENT OF IN-PATIENT TREATMENT:
YES
NO
HOSPITAL OR FACILITY:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
WHAT WAS THE OUTCOME/RESULTS:
FAMILY INFORMATION
MARITAL STATUS:
CHILDREN:
AGES:
SPOUSES NAME:
ISSUES WITHIN THE RELATIONSHIP:
FINANCIAL
DO YOU RENT OR PURCHASING A HOME?
DO YOU HAVE ANY FINANCIAL ISSUES?
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ADDITIONAL QUESTIONS
DO YOU KNOW WHY IT’S BEEN REQUESTED YOU ATTEND A RETREAT?
DO YOU KNOW WHO RECOMMENDED YOU ATTEND A RETREAT?
WHAT DO YOU EXPECT TO GAIN BY ATTENDING THE RETREAT?
DO YOU SUFFER FROM DEPRESSION?
YES
NO
DO YOU SUFFER FROM ANXIETY?
YES
NO
MEDICATIONS:
DO YOU WANT TO IMPROVE YOUR OVERALL MENTAL HEALTH?
YES
NO
PLEASE EXPLAIN:
ARE YOU WILLING TO DO THE WORK TO IMPROVE YOURSELF?
YES
NO
PLEASE EXPLAIN:
WHAT DO YOU WANT TO GAIN FROM ATTENDING THE RETREAT?
**TRIGGER RESPONSES STAFF SHOULD BE AWARE OF:
DO: (i.e., talk to me, be present in silence, touch shoulder, give me space, etc.)
DON’T: (i.e., no touch, no talk, don’t sit close, etc.)
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