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Mindful Grieving 200 Hour
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Art of Sacred Listening Retreat Registration
First Name
Last Name
Email
Street Address
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City
Region/State/Province
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Phone Number
Is it okay to leave a private voice message?
Yes
No
What is the best way to contact you?
Email
Phone
Text Message
Birthdate
Occupation
Marital Status
Single
Married
Significant Other
Widowed
Seperated
Divorced
Other
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Do you have children?
Yes
No
Have you ever participated in a Mindful Grieving Program in the past?
Yes
No
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Email
Food Restrictions
Dairy-Free
Gluten-Free
Sugar-Free
Vegetarian
Vegan
Pescatarian
Nut Allergy
Shellfish Allergy
Soy Allergy
Other
Food Preferences
Fish
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Other
Do you have a regular meditation practice?
Yes
No
Do you have any experience teaching or participating in yoga therapy for grief programs?
Yes
No
If so, please explain.
What special qualities or gifts do you possess that will be an asset in this arena of work?
Do you want to facilitate community circles upon successful completion of this program?
Yes
No
Maybe
If so, please list any specific populations that you are interested in working with.
Please tell us why you're interested in participating in this training retreat. Please write at least two or three paragraphs around your aspiration and intention.
What kind of loss have you experience (select all that apply)?
Divorce
Miscarriage
Stillbirth
Suicide
Relationship
Child
Spouse
Parent
Sibling
Friend
Grandparent
Pet
Job
Identity
Disability
Illness or Injury
Military Service
Incarceration
Life Changing Event
Collective Grief
Other:
When did your loss(es) occur?
Yes
No
How is your loss affecting you now?
Have you had more than one loss in the past 5 years?
Yes
No
Are you currently in counseling?
Yes
No
What is your current support system?
Have you experience any events that you would consider traumatic, whether related to this loss or not?
Yes
No
If so, please explain.
Have you ever attempted or considered suicide?
Yes
No
If so, was there any follow up treatment? If so, what?
Are you currently taking medications for depression, anxiety, or other mental health issues?
Yes
No
Have you ever been hospitalized for psychiatric or other reasons?
Yes
No
If so, please list.
Is there anything else you would like for us to know?
How did you hear about CSG?
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