Rachel’s Vineyard Retreats Registration & Questionnaire

The retreat and registration process are confidential and the names of all retreatants are kept in strictest confidence.

Registration

I am registering for the retreat on *

First Name *

Last Name *

Name you prefer to be called (If different)

Home Phone *

Mobile Phone

Work Phone (Optional)

Address *

City, State & Zip *

Email Address *

May we contact you by letter? *

May we contact you by email? *

May we leave a message on your voice mail? *

Please indicate the best time(s) to call

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

Emergency Contact Name *

Emergency Contact Home Phone *

Emergency Contact Mobile 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? *

Are you currently in counseling or therapy? *

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

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.

How did you hear about this retreat? *

Do you have any questions, comments or concerns? *

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Rachel’s Vineyard Retreats Registration & Questionnaire