Posted on November 6, 2017 Posted By: Debbie Crowley Categories: RETREAT REGISTRATION 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. CompanyThis field is for validation purposes and should be left unchanged.I am registering for the retreat onOctober 24-26, 2025 (English) (OKC)March 6-8 2026 (Spanish)April 24-26, 2026 (English) (OKC)May 15-17 2026 (English)June 19-21 2026 (Spanish)October 23-25, 2026 (English) (OKC)I cannot register for this retreat, but please contact me before the next one.Name First Name Last Name Name you prefer to be called (If different)Mobile phoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email May we contact you by letter?YesNoMay we contact you by email?YesNoMay we leave a message on your voicemail?YesNoPlease indicate the best time(s) to callIn case of emergency during the retreat, who may we contact?Emergency contact nameEmergency contact phoneTheir relationship to youYou will be have a private room and bath. Do you have any special needs?YesNoDo you require a special diet?YesNoQuestionnaireThe 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.AgeMarital statusSingleMarriedDivorcedSeparatedHave you kept the abortion a secret?YesNoWho 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?YesNoHave you lost other family members?YesNoDo you have living children?YesNoHave you had any counseling or therapy regarding the abortion?YesNoHave you ever been diagnosed with any emotional or psychological disorder(s)?YesNoAre you currently in counseling or therapy?YesNoAre you on any medication for psychological reasons?YesNoDo 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?
