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Awakening Through Grief Retreat Registration
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Single
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Do you have children?
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Have you ever participated in a Mindful Grieving Program in the past?
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Emergency Contact Name
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Emergency Contact Email
Food Restrictions
Dairy-Free
Gluten-Free
Sugar-Free
Vegetarian
Vegan
Pescatarian
Nut Allergy
Shellfish Allergy
Soy Allergy
Other
Food Preferences
Fish
Poultry
Red Meat
Other
Do you have any rooming / roommate preferences? (i.e. sleeping habits)
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?
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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.
Do you experience fighting in your household?
Yes
No
If so, please explain.
Do you currently practice yoga?
Yes
No
Is there anything else you would like for us to know?
How did you hear about CSG?
Register
Awakening Through Grief Retreat Registration
Last Name
First Name
Email
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
arrow&v
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
Decline to Answer
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
Poultry
Red Meat
Other
Do you have any rooming / roommate preferences? (i.e. sleeping habits)
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.
Do you experience fighting in your household?
Yes
No
If so, please explain.
Do you currently practice yoga?
Yes
No
Are you currently pregnant?
Yes
No
Is there anything else you would like for us to know?
How did you hear about CSG?
Register
October 2023 - Maui
Awakening Through Grief Retreat Registration
Last Name
First Name
Email
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
arrow&v
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
Decline to Answer
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
Poultry
Red Meat
Other
Do you have any rooming / roommate preferences? (i.e. sleeping habits)
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.
Do you experience fighting in your household?
Yes
No
If so, please explain.
Do you currently practice yoga?
Yes
No
Are you currently pregnant?
Yes
No
Do you have any injuries or disabilities that will affect your practice?
Yes
No
If so, please list.
Please tell us why you're interested in participating in the Awakening Through Grief Wellness Retreat.
Is there anything else you would like for us to know?
How did you hear about CSG?
Register
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