Retreat Intake Form

Retreat Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
E-mail*
example@example.com
Phone Number*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number
Occupation*
History of Mental
1. What are you experiencing in terms of your mental health?
2. Have you been diagnosed with any specific mental health conditions? Please specify.
YesNo
If yes, please specify:
YesNoSometimesHave in the past
DepressionSleep DistrurbancesChronic TirednessAnger & OutburstsVoicesNegative Mind ChatterAddictionsDangerous ThoughtsChronic SadnessAnxietyNightmaresNumbFeeling Hopeless
What are some of the stressors in your life that are affecting your mental health?
YesNo
WorkRelationshipsFinancesHealthFamilyPast Experiences or Trauma
8. Is there anything else you'd like us to know about?
Do you have any dietary restrictions or special needs that we should be aware of?
Consent and Confidentiality
YesNo
YesNo
Client Agreement: (Client services and chart information are confidential )

You understand that you have not been threatened or persuaded to undergo or partake in any particular treatment, medication or substance and that attending it will be at your own risk and discretion.

Cancellation: Cancellations have such an impact on our business and we appreciate having as much notice as possible. Cancellations within 20 days of the retreat will forfeit your deposit. No showing the retreat will result in a fee of 100% of payment.

You agree that by accepting these terms that you assume all risk of participating and release Johnny Batterson, The Medical Healer International and associates from all liability including travel to and from the Service or any events incidental.

By my electronic signature below, I agree to this policy and client agreement above.
Date

MonthDayYear
Date
Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
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Retreat Intake Form

History of Mental

Consent and Confidentiality