CompleteYour Bali Retreat RegistrationTo complete your retreat registration, please fill out this form. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Is it okay to leave a private voice message? * Yes No What is the best way to contact you? * Email Phone Text Message Birthdate * MM DD YYYY Occupation Marital Status * Single Married Significant Other 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 * Country (###) ### #### Emergency Contact Email * Food Restrictions Dairy-Free Gluten-Free Sugar-Free Vegitarian 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 experienced (select all that apply)? * Divorce Miscarriage Stillbirth Suicide Relationship Child Spouse Parent Sibling Grandparent Friend Pet Job Identity Disability Illness or Injury Military Service Incarceration Life Changing Event Collective Grief Other If other, please explain When did the losses occur? Have you had more than one loss in the pat 5 years? * Yes No How is your loss affecting you now? * Are you currently in counseling? * Yes No What is your current support system? * Have you experienced 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? Is so, please list. * Please tell us why you're interested in participating in this Retreat. * Is there anything else you would like for us to know? How did you hear about CSG? * Thank you so much for joining us! If you haven’t already, please complete the Participant Agreement.
