Women's Weekend Retreats Referral Form

Women's Weekend Retreats Referral

This referral must be completed by a BOP Therapy Foundation approved Counsellor, Social Worker, Mental Health Worker or 'Other' Health Professional, with permission from the Applicant.
The criteria for this retreat is that participants:
1. Must be experiencing stress-related difficulties
2. Would find it financiallydifficult to take a break
3. Are in a cargiving role in some capacity eg. disabled person, parent, grandparent, partner or a professional role that is responsible for others
Referrer details

Please let us know your details
Name*

First NameLast Name
Organisation Name*
CounsellorPsychologistMental Health WorkerHealth ProfessionalPastorSocial Worker /TherapistOther
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
As a referrer, based on the criteria provided, I believe the person I am referring meets the Women's Retreat criteria. I am confident that she is not displaying any behaviour or current conditions which may place herself or other participants at risk and would benefit from the rest, recuperation and support provided by the Bay Restore Women's Retreat (funded through Bay of Plenty Therapy Foundation).
Signature*
Date*

MonthDayYear
Date
Retreat Dates

Please indicate which retreat you are referring for. We do our best to accommodate requests but referrals are subject to confirmation.
Which retreat are you referring for?*
Referee Details

Please provide the details of the person the referral is being made for
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Cultural Identity*
Collected for statistical purposes only, individuals will not be identified
Who is care being provided for*
Collected for statistical purposes only, individuals will not be identified
Age Group*
Collected for statistical purposes only, individuals will not be identified

Support Person

A family member or friend who will be able to collect you if needed
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
As a participant I understand the criteria for being accepted to attend a retreat and confirm that I would like to engage in a Retreat for Women that offers education and rest.

I also understand and agree that:
- I am happy to be contacted by Bay Restore Women's Retreat Facilitator for assessment purposes prior to the retreat (if necessary)
- it is not a counselling retreat and that facilitators are unable to provide one-on-one counselling support.
- if I begin to experience levels of distress and am finding it difficult to cope, I agree that I will go home (the facilitators will check with you to see if you feel safe to drive home or whether you would like your support person to collect you)
Signature - Participant*
Date*

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
Stress-related difficulties
Anxiety
Depression (mild to moderate)
Issues with alcohol and/or drugs
Domestic violence issues

Rows	Yes	No	Not applicable
Participate in a three-day residential retreat
Be willing to engage in developing a follow-up plan with your referrer (if necessary)
Refrain from any non-prescriptive drugs or alcohol throughout the retreat

Women's Weekend Retreats Referral

Referrer details

Retreat Dates

Referee Details

Information about the person being referred

Support Person