Registration Form: (May 2017) NDIP Retreat #3: Disentangling Nervous Systems

Disentangling Nervous Systems, Addressing Addiction and
Unlocking Self-Sabotage

(May 19-26, 2017)
with Susan Skye and Sarah Peyton

We're delighted you'll be joining us in Portland, Oregon, USA.
To register, please provide the following information.

If you have any questions, please don't hesitate to contact us at newdepthsjourney@gmail.com or 503-862-9224.

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LODGING WILL BE OFFSITE for nights 1 & 2 of the May retreat. A twice daily shuttle will get you to and from your lodging.

Lodging will be at the retreat center for the remaining retreat days.

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Your Contact Information

First Name*

Last Name*

Address - Line 1*

Address - Line 2

City*

State or Province*

ZIP/Postal Code*

Country*

Email Address*

Phone Number*

Country CodeArea CodePhone Number

Phone Number (re-enter)*

Skype ID

Time Zone (UTC)

How did you first hear about New Depths?*

What New Depths retreats have you previously participated in? (please check all that apply)*

I've completed a previous New Depths Intensive Program (2010, 2012, 2013, 2015)October 2016January 2017This will be my first New Depths "Intensive Program" retreat

Have you previously participated in any other New Depths program (BESIDES those noted above)? If yes, which one(s)?

Our Program Values & Requested Commitments

The following is a list of values that we'd like our participants to resonate with:

A desire to learn about the brain research findings that relate to healing unresolved childhood pain and promoting well-being

A willingness to engage in and/or witness inner work that may involve intense emotional content

A willingness and ability to be part of a group and to speak in the group

A willingness to value both your own needs and the needs of the other members of our community

1) Do you resonate with our program values? (NOTE: If "no," a New Depths retreat may not be the best way to meet your needs at this time.)*

YesNoOther

An essential component of the retreat's effectiveness is the resonant, empathic community that we create during the time we spend during our residential retreat week together.

For this reason, we ask that you honor the container of this sacred healing space and arrive at the retreat center no later than 5pm on the first day of the retreat, and depart from the retreat center no earlier than 1pm on the last day of the retreat.

Arrival and departure times for this retreat are:

ARRIVAL: 5pm Friday May 19 (check-in begins at 4pm, dinner is at 6pm)
DEPARTURE: 1pm Friday May 26 (or later)

2) Are you committed to attending all days of the retreat? (Arriving at the retreat center by 5pm on the first day, and departing the retreat center after 1pm on the last day of the retreat.)*

YesNoOther

Your Hopes and Intentions

What are you hoping for, from your participation?*

Your Background/Previous Experience

We would enjoy knowing something about your background. (Note, you don't need any experience in these areas in order to profoundly benefit from the retreat.)

1) Do you have any experience with meditation or any other form of presence practice?*

YesNo

1a) IF YES, please share a few words with us about your experience.

2) Do you have any experience with Nonviolent Communcation (NVC, or Compassionate Communication)?*

Yes, I'm a CNVC Certified NVC TrainerYes, I'm an Independent NVC TrainerYes, I have experience with NVC (other than teaching NVC)No

2a) IF YES, please share a few words with us about your experience.

3) Are you familiar with the "Living Energy of Needs"?*

YesNo

4) Are you a mental health professional?*

YesI'm in training to become a mental health professionalNo

4a) What is (are) your specific field(s) and/or approach(es)?

5) Do you work in the field of personal development? (nonprofessional mental health, coach, etc.)*

YesI'm in training in the field of personal developmentNo

5a) Are you associated with any particular group(s) or modality(ies)?

6) Do you have any previous personal or professional experience with brain research and/or interpersonal neurobiology?*

YesNo

6a) IF YES, please share a few words with us about your previous experience.

7) Do you have any previous personal or professional experience with trauma and its treatment?*

YesNo

7a) IF YES, please share a few words with us about your previous experience.

Your Preferences

Collecting this information will help us to make the retreat experience as comfortable and supportive as possible for you.

LODGING WILL BE OFFSITE for nights 1 & 2 of the May retreat. A twice daily shuttle will get you to and from your lodging.

Lodging will be at the retreat center for the remaining retreat days.

1) What kind of lodging arrangement would you like?*

Private RoomRoommate (I have one already)Roommate (please assign one for me)Local Commute ($475 board only)

1a) If you already have a roommate, please enter their name here:

2) What is your gender?*

FemaleMaleOther

3) Please let us know about any special room needs you have.

Fragrance-freeIn-room internet access (NOTE: At Collins Retreat Center this amenity has extremely limited availablity, which we would like to reserve for those whose frequent daily access to the internet has a direct impact on their livelihood. 24-7 wireless internet access is available to all in the common areas.)Other

4) How do you plan to travel to the area (Eagle Creek, Oregon, USA, 45 minutes southeast of Portland, Oregon)?

By airplane (into Portland, Oregon, airport code = PDX)By train (into Portland, Oregon)By car (directly to the Collins Retreat Center in Eagle Creek, Oregon)By local rental carNot sure yet

5) Would you like to participate in the ARRIVAL AIRPORT SHUTTLE POOL, that would reduce your shuttle costs by about 50% (from $60 to $75 down to $30 to $35)? (If you say "yes" or "not sure yet," we'll contact you about 4 weeks before each retreat to get your flight information. About 1 week before each retreat we'll send you a draft arrival shuttle schedule, and you can commit at that time to participating in the arrival shuttle or not. Departure shuttles are organized during the retreat.)

YesYes-wheelchair accessibleNoNot sure yet

Investment and Discount Details

1a) Are you registering with a friend or colleague? (Receive $100 tuition discount per person, per retreat!)

YesMaybeNo

1b) If you are registering with other(s), please provide their name(s) here.*

2) How do you prefer to pay your nonrefundable registration deposit?*

SINGLE RETREAT WEEK: $300 by checkSINGLE RETREAT WEEK: $310 online, including $10 processing feeOther

After March 19, 2017 payment in full is due with your registration. After you submit your application, on the next page you'll find a link you can click to pay your program fees with your credit or debit card.

Terms and Policies

1) DEPOSIT TERMS: Your $300 nonrefundable registration deposit must accompany your application. You will receive a confirmation e-mail and balance payment schedule when you are accepted into the program. (If you are not accepted, your deposit will be refunded in full.) Once you have been accepted into the program, your registration deposit is non-refundable.*

I have read and accepted the Deposit Terms.

2) TRANSFER, CANCELLATION, AND REFUND POLICIES: If you cancel 35 or more days before the program starts *and* we are able to fill your place in the program with another paying participant, you'll receive a full refund, minus your nonrefundable registration deposit and any processing fees. You may transfer your discounts and payments to the next retreat week one time, with the following fees: Up to 35 days before retreat start date: 15% tuition transfer fee, no room/board cancellation fee; 20-34 days before program start: 15% tuition transfer fee, $50 room/board cancellation fee; less than 20 days before program start: 15% tuition transfer fee, 100% room/board cancellation fee. Thirty-five (35) or more days before the retreat start date you may transfer 100% of your registration fees and applicable discounts to another participant if that person is accepted into the retreat, for an additional $150 administrative fee. Refunds are not available if you cancel after the start of your retreat week, if you do not show up, or if you leave the retreat early.*

I have read and accepted the Transfer, Cancellation, and Refund Policies.

2b) FULL PROGRAM TRANSFER, CANCELLATION, AND REFUND POLICIES: If you cancel 35 or more days before the program starts *and* we are able to fill your place in the program with another paying participant, you'll receive a full refund, minus your $600 nonrefundable registration deposit and any processing fees. Thirty-five (35) or more days before the program start date you may transfer 100% of your registration fees and applicable discounts to another participant if that person is accepted into the program, for an additional $300 administrative fee. Refunds are not available if you cancel after the start of the program (your first retreat week), if you do not show up, or if you leave the program early.

I have read and accepted the FULL PROGRAM (3 Retreat Weeks) Transfer, Cancellation, and Refund Policies.

3) Is there anything else you'd like us to know?

.

Click "SUBMIT" below to save your application and receive instructions for how to pay your registration payment.

(Your application is not complete until we receive your payment.)

Once we receive your application and payment, your completed application will be processed within 5-7 business days, and we will contact you by email to provide you with the next steps.

Questions? Please included them in #3, above.

Warmly,

Susan and Sarah
New Depths

For security, please enter the contents of the field below.*

Registered for Retreat Week #3 (May 19-26, 2017)

May 19-26, 2017