Rachel’s Vineyard Retreats Registration & Questionnaire

Posted on November 6, 2017 Posted By: dcrowley Categories:

Register for Rachel's Vineyard Retreat for Healing After Abortion

If you have questions about this form or about the retreats, you may call us at (918) 508-7142.

I am registering for the retreat on

Name

First Name Last Name

Name you prefer to be called (If different)

Mobile phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

May we contact you by letter?

May we contact you by email?

May we leave a message on your voicemail?

Please indicate the best time(s) to call

In case of emergency during the retreat, who may we contact?

Emergency contact name

Emergency contact phone

Their relationship to you

You will be have a private room and bath. Do you have any special needs?

Do you require a special diet?

Questionnaire

The following questions are very personal, but your answers will help us to understand where you are in your healing process and whether you have any special needs that we should be aware of. All inquiries are confidential.

Age

Marital status

Have you kept the abortion a secret?

Who will attend the memorial service with you? What is their relationship to you?

How long has it been since your abortion?

How old were you at the time?

Have you lost any other children?

Have you lost other family members?

Do you have living children?

Have you had any counseling or therapy regarding the abortion?

Have you ever been diagnosed with any emotional or psychological disorder(s)?

Are you currently in counseling or therapy?

Are you on any medication for psychological reasons?

Do you have any medical problems, special needs, or dietary needs that we should be aware of?

Is there anything else you would like us to know about you?

What religious faith are you?

You do not need to be Catholic or even Christian to participate in a Rachel's Vineyard Retreat. The retreat is Catholic in its presentation and you will have opportunities to attend Mass and to receive private counseling from a priest.

Do you have any questions, comments or concerns?

How did you hear about this retreat?

Name

This field is for validation purposes and should be left unchanged.

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