HFN - Retreats: The Next Step

To secure your place at an upcoming retreat we will need your completed questionnaire and a deposit of $500. The balance can be paid before or at registration. Even if you decide that you would like to attend at the last minute. Call our office and check with us to see if there is a spot available for you. We also want to talk to you by telephone to confirm your acceptance and discuss any questions you may have. Our phone numbers are listed at the bottom of the page.

RETREAT CANDIDATE QUESTIONNAIRE

The most convenient way to apply is to fill out the questionnaire online. Scroll down to begin.
You may also download our Microsoft Word version, type out your responses, and then copy and paste the text into an email.
If you want to use with the Email Version, click here to download the form (requires Microsoft Word). You will be prompted to open up a file, or to save to disk. Feel free to save this file, which is called questionnaire.doc (unless you choose to rename it). Make a note of where your computer downloads and stores the file. Then you open this file with your word processor (you can be offline for this). Answer the questions, then choose the entire text and click on "Copy." Open an email to HFNsite@earthlink.net and click on "Paste."
If you have difficulty, please call us at 1-800-483-2841.
You may also open our PDF version, print it, fill out your answers and mail it to us.
Click here to open the PDF file. You will need Adobe Reader to view this file. You may then print the file, hand-write your responses, and mail it in to Healing for the Nations • P.O. Box 677 • Marietta, Georgia 30061-0677 • USA

ONLINE RETREAT CANDIDATE QUESTIONNAIRE

Which retreat do you want to attend?

Retreat Dates

PERSONAL HISTORY

Name

Age Birthdate

Home Phone Business Phone

Cell Phone Emergency Contact Phone

Address

City State Zip Code

Country

Single Married Separated Divorced Widowed

(If married) Spouse's name

Anniversary Date

IF QUESTION DOES NOT APPLY, PLEASE TYPE "NA"

1. Please describe the reasons you would like to attend a retreat. Please include the struggles you are experiencing.

2. Have you had previous counseling and/or hospital treatment? If so, please describe the type of counseling, when, and where. Would you describe this experience as helpful? If not, please explain.

BACKGROUND INFORMATION

3. Describe the relationships with your family (the family you grew up with.) How were problems resolved? Was there any history of physical or sexual abuse?

4. Please describe major physical or emotional problems that you experienced since your childhood.

5. (If applicable) Is your marriage supportive? Please describe.

6. If you have children, please indicate the following:

Child(rens) Name(s):

Child(rens) Age(s):

Living With Whom:

7. With whom do you presently live and for how long? Are there any particular problems or difficulties in this situation? Please describe.

PHYSICAL INFORMATION

8. Please list all medications you are currently on if any. Prescription(s) and purpose(s).

9. Please check the following if applicable:

Heart Problems: Past Current Comments

Diabetes: Past Current Comments

Hypoglycemia: Past Current Comments

Epilepsy: Past Current Comments

Hepatitis A,B,C: Past Current Comments

Allergies: Past Current Comments

Other: Past Current Comments

10. Are you currently under a physicians care for medical problems? If so, please explain.

11. Please list problems that we need to be aware of in order to properly care for you should a problem arise during the retreat. Include special dietary needs, etc.

12. Should any medical problems arise, you will be expected to take care of any expenses associated with your care. Please list any pertinent insurance information in case of an emergency situation.

Insurance Carrier: Policy No.:

13. Have you ever used illicit drugs? Have you used prescription or over the counter drugs inappropriately? It is very important to state when you last used. If you have had problems with alcohol, please include this.

EDUCATION

14. Please indicate the highest completed:

High School
Attended College
College Graduate
Post Graduate Studies
Masters Degree
Doctorate

15. Please describe any learning disabilities or struggles that might interfere with your retreat experience.

EMPLOYMENT

16. Please describe your current position, title, and how long you have been in this position. Please include any other aspects of your employment history that would be helpful for us to know.

RELIGIOUS AND SPIRITUAL INFLUENCES

17. Denominational preference and background.

18. Please describe any involvement in cults and/or the occult.

SUMMARY

19. What goals do you have regarding the outcome of the retreat?

P.O. Box 677 • Marietta, Georgia 30061-0677 • USA
Telephone: +1 (800) 483-2841 (within the US)
Outside US: +1 (770) 919-0140
Fax: +1 (770) 919-1323
e-mail: hfnsite@earthlink.net