Retreat Interest Form
This retreat is intentionally small and thoughtfully curated to foster meaningful conversations, trust, and connection. Please take 10-15 minutes to answer the questions below. There are no "right" or "wrong" answers. Your responses simply help to determine whether this retreat is a good fit for you.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When were you diagnosed with ocular melanoma?
Within 6 months
6-24 months
More than 2 years ago
I have metastatic disease
Briefly tell us your ocular melanoma story:
Describe what has been the most difficult part of your journey:
What prompted you to consider this retreat?
What 3 things would you like to gain from the retreat?
Indicate which topics you are most interested in exploring:
More knowledge about ocular melanoma
Living with uncertainty
Relationships
Stress & nervous system regulation
Connecting with others
Holistic health
Survival plan
Other
Community: The retreat is interactive and relationship-centered. Which statement describes you best?
I enjoy sharing openly in groups
I tend to listen more than speak
I'm nervous about sharing but willing to try
I'd rather keep mostly to myself
Other
How comfortable are you hearing about other people's cancer experiences?
Very comfortable
Somewhat comfortable
Unsure
Somewhat uncomfortable
Quite uncomfortable
How would your family or close friends describe you?
List any concerns you have about attending:
Why do you believe you are meant to attend this retreat?
Commitment: This retreat involves honest conversation, participation and respect for everyone's privacy. Select all you are willing to do:
Maintain confidentiality
Participate respectfully
Be present without distractions
Contribute to a supportive environment
Will you attend with a support partner?
No
Yes - please have your support partner complete the retreat interest form separately
Submit Interest
Should be Empty: