Retreat Registration – Kentucky – Rachel's Vineyard of Kentucky

Name(Required)

Address(Required)

Phone number(Required)

Email(Required)

Religion(Required)

Marital Status / How many Children(Required)

How did you hear about Rachel's Vineyard?(Required)

How can we help you?(Required)

What are you hoping to get from this retreat?

How many children are you grieving?(Required)

Are your losses from abortion, miscarriage, or stillbirth?(Required)

Relationship to the children?(Required)

Have you ever seen a therapist, psychiatrist, or psychologist?(Required)

If so, what issues did you talk about?(Required)

This will enable our team's therapist to be aware of any issues that might affect you during your retreat.

Do you have a specific diagnosis?(Required)

Are you currently on any medications that we should be aware of?(Required)

Any dietary concerns?(Required)

Please share any food allergies that you might have.

Any medical concerns / handicaps?(Required)

Will anyone be making the retreat with you?

If so, please provide his or her name.

Your Emergency contact:(Required)

Please provide name and phone number.

Do you need financial assistance for this retreat?(Required)

The cost is $250 for the entire weekend; grants are available for those who need assistance.

If yes to above, how much can you afford to pay?

Which retreat are you planning to attend?(Required)

We offer multiple retreats each year, so please tell us which retreat you are planning to attend.

Method of Payment of Deposit(Required)

Will you be paying by credit card or sending a check? If paying by check, please send it to: Rachel's Vineyard / 806 Shaker Museum Rd. / Auburn, KY 42206

Rachel's Vineyard Retreat Registration - Kentucky

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