Clone of Awakening Retreat Registration

AWAKENING Retreat Registration:

Fill out the information below to reserve your place at the retreat. Please complete the form in its entirety. The key to a successful retreat is your ability to be authentic, honest, and vulnerable. It is also very important for you to be non-judgmental in order to create a safe environment for all participants.
Participant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Date of Birth*

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Food Allergies*
Dietary restrictions

Gluten FreeVegetarianVeganDairy FreeOther
Dietary preferences
Please advise of any non-allergy food preferences (dislikes, etc)
Please list any medical issues we may need to be aware of
Are you a current or former client of Christina Alston, LPC?

YesNo
Are you currently seeing a mental health professional? (Check all that apply)

Counselor/TherapistPsychologistPsychiatristNoneOther
Previous psychiatric treatment (check all that apply)

Medication for Psychiatric DisorderInpatient Psychiatric HospitalizationIndividual CounselingGroup CounselingSupport GroupsOther
If you have been hospitalized in a psychiatric hospital, please list the last 3 hospitalization dates and reasons for hospitalization:
Have you ever been diagnosed with any of the following:*

Bipolar DisorderSchizophreniaPersonality DisorderNone of the above
Are you currently experiencing any of the following (check all that apply and provide a brief description below):

DepressionIntense AnxietyCurrent substance abuseHallucinationsThink people are trying to harm youHurting yourself (cutting, scratching, skin picking, burning)Thoughts about ending your lifeMaking plans to end your lifeRecently made attempt to end your life (past 6 months)Plans or attempts to end your life in the pastCurrent abuse (physical, sexual, verbal, emotional, etc)
Provide additional details for any items checked above.
How would you describe your faith currently?*
What sparked your interest in this retreat?*
What do you hope to gain as a result of this retreat?*
Is there anything else we should know about you before you attend the retreat?
Questions or Comments:
Payment options will be sent to you separately once registration is complete. You may make a deposit or pay in full. Your spot will not be guaranteed until payment is received.

**Due to the exclusive nature of this retreat and the extensive planning required, all payments are non-refundable. Thank you for your understanding.
Room Options*
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Private king master bedroom with private bath - main level$1,250.00
Private bedroom on the main level featuring a king bed and ensuite bathroom.

Private king master bedroom with private bath - upstairs$1,250.00
Private bedroom on the upper level featuring a king bed and private bathroom (not attached).

Private queen bedroom with private bath - upstairs$1,250.00
Private room on the upper level featuring a queen bed and ensuite bathroom.

Private queen bedroom with shared bath - upstairs$1,200.00
Private room on the upper level featuring a queen bed with a Jack and Jill bathroom.

Shared (double occupancy) bedroom with shared bath - twin beds$1,000.00
Shared room on the upper level with two twin beds with a Jack and Jill bathroom.

Total $0.00
Upload a copy of the front and back of a valid form of photo ID (driver's license, state ID card, passport).**

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*The purpose of this information is to provide proof of your identity and prevent fraud. With registrations being completed online and due to the intimate nature of this retreat, it is imperative that we protect the event and the participants. Cancelof
I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts may render this registration void and will be cause for forfeiting my reservation for the retreat and forfeiting any funds paid. Sign below*

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AWAKENING Retreat Registration: