Apply for a Renew Retreat

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Name *

First

Last

Date of Birth *

Email *

Address *

Line 1

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City

State

Zip Code

Country

Phone Number *

What area of your life would you like extraordinary results? *

What specifically would you like to accomplish at the Renew Retreat? *

What in your observation has kept you from accomplishing these results? *

What resources and coping skills do you already utilize? *

If you are in a relationship, please describe the nature of the relationship and months or years together. *

Describe your current living situation. Do you live alone, with others. With family, etc... *

Are you currently under the care of a therapist? If not, have you gone to therapy in the past and how long ago? *

List any mental health diagnoses by a professional. *

What medications are you currently prescribed? *

Do you have suicidal thoughts or have had them in the past? Have you had a suicide attempt? How long ago? *

Do you have a history of any hospitalizations related to mental health? How long ago? *

Do you have thoughts of harming others or have had these thoughts in the past? How long ago? *

Do you have a history of drug and alcohol abuse or dependence? How long ago? *

Do you have any medical issues that might affect your participation in the Renew Retreat? *

Is there anything else you would like to share about yourself? *

Which Renew Retreat are you interested in attending? *

I understand that Renew Retreats include lodging, food, and therapeutic services. Transportation to and from the retreat is not included.

I understand. Type initials below. *

I understand all pricing is per person and in US dollars. The cost of Renew Retreats is $5000.00 (US dollars) with a credit card processing fee of $200.00 (US dollars). If the registration is paid in full at the time of registration you will receive a $100.00 discount.

Payment plans are available, and deposit payment of 25% ($1,300) is due at the time of registration The first payment of 50% ($1,950) of the remaining balance is due 60 days prior to the retreat, and the remaining balance of 50% ($1,950) is due 30 days prior to the retreat.

I understand. Type initials below. *

I would like to *

This application will be reviewed by one of our therapists, who will follow up with you within 48 business hours. To complete the registration for a Renew Retreat, you will next meet with one of our therapists to discuss your application and goals for the Renew Retreat. Completing this application does not guarantee a spot in a Renew Retreat. If it is determined by one of our therapists that a Renew Retreat is not an appropriate fit for you, every effort will be made to refer you to an appropriate level of care.

I understand. Type initials below. *

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