Healing After Pregnancy Loss Registration
Register for a warm, trauma-informed mini-retreat for women who have experienced pregnancy loss. This supportive form includes event details, registration options, accessibility needs, emergency contact information, and retreat agreements. This retreat will be facilitated by Lycia Rodrigues, Registered Clinical Counsellor - Women's Mental Health - and Matty Cervantes, PhD candidate, artist and educator and healer using creative expressions.
Website
www.oceanos-counselling.com
Participant Details
Participant Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pronouns
How did you hear about this retreat?
Sharing and Accessibility
Briefly share anything you’d like the facilitator to know about your experience with pregnancy loss
Do you have any accessibility needs or accommodations that would support your participation?
Do you have any allergies or dietary needs related to refreshments/tea?
Anything else you’d like to share with Lycia before the retreat?
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
Registration and Contact Preferences
Select your registration type
*
Please Select
Standard registration – $180
Requesting funded spot
If you have a funded spot code, please enter it here
Preferred method of contact for retreat updates
*
Please Select
Email
Phone
I consent to be contacted by email with retreat details and any follow-up information, including potential ongoing group offerings
I consent
I do not consent
Agreements and Payment
I understand this is a small group (max 12 participants) and my spot is confirmed upon registration.
Acknowledgment of Supportive Nature
*
I understand this mini-retreat is therapeutic and supportive in nature and is not a substitute for individual medical or psychiatric care.
Confidentiality Agreement
*
I agree to keep other participants’ stories and identities confidential.
Retreat Fee ($180)
*
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Mini-Retreat Registration
Healing After Pregnancy Loss mini-retreat fee
$
180.00
Payment is via e-transfer to lycia@oceanos-counselling.com.
Participants can request receipt for reimbursement with your benefits
Discount Code for Funded Spot
Website
www.oceanos-counselling.com
Thank you for your interest in this space. I will be in touch shortly with next steps.
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