Kopie Registration

First Name:

Last Name:

Gender:

Birthday:

E-Mail:

Phone:

Address

Retreat I want to join:

Are you currently seeing a counselor, psychiatrist, or psychologist?

Yes

No

If yes, please specify:

Are you now being treated or have you ever been treated for any mental health conditions, including, for example (but not limited to) PTSD, psychosis (including drug-induced psychosis), chronic anxiety, bi-polar disorder, and sleeping disorders that required taking any form of medication and/or hospitalization?

Yes

No

If yes, please specify:

Have you ever been a patient in a mental health care facility?

Yes

No

If yes, please specify:

Are you currently taking or have been prescribed psychiatric medications? If yes, please share which prescriptions, for what diagnosis, for how long and the results?

Yes

No

If yes, please specify:

Have you ever been diagnosed with any type of personality disorder?*

Yes

No

If yes, please specify:

Are you currently under the care of a medical doctor?

Yes

No

If yes, please specify.

Are you currently taking any medications?

Yes

No

If yes, please specify:

Do you currently have any communicable diseases?

Yes

No

If yes, please specify:

Which retreats or groups did you attend in the field of personal/self development

Retreats/Groups:

Please take a moment to read through Terms and Confidentiality Agreement (see link below) and confirm your acceptance by marking the check box below.

I agree.

Please take a moment to read through the Privacy Policy (see link below) and confirm your acceptance by marking the check box below.

I agree.

Retreat Registration