Retreat Registration – Kentucky

Your name

Your phone number

Your mailing address

Your email

What is the best way to contact you? Best time of day?

Marital status

Religion

How did you hear about Rachel's Vineyard?

What do you hope to receive from this retreat?

How many children are you grieving?

Are you grieving from abortion, miscarriage, or stillbirth?

Relationship to the children
ParentGrandparentSiblingOther

Symptoms of Trauma and Grief
GuiltAnxietyGrief / SadnessDepressionSuicidal thoughtsInability to forgive myselfAlcohol / Drug AbuseOvereating or Under eatingOther addictions

More Symptoms of Trauma and Grief
Self harmAngerMarriage problemsSpiritual issuesBouts of cryingSexual problems / promiscuityNightmares / sleep disturbancesFlashbacksLowered self esteem

Have you ever seen a therapist, psychiatrist or psychologist?

What issues did you talk about?

Did you have a specific diagnosis? Which ones?

Any food allergies, dietary concerns or handicaps?

Emergency contact person and phone number

Do you need financial assistance (cost is $250 for the entire weekend), if so, how much?

Which retreat are you planning to attend?
Western Kentucky Catholic RetreatLouisville Catholic RetreatCullman Alabama Catholic RetreatMiddle Tennessee Interdenominational Retreat

Any additional information that you would like to share (optional)

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