Name
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First Name
Last Name
Email
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Year of Birth
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Gender Identity
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Occupation
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Are you here on retreat with anyone?
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If so, what is their name?
Name of someone we can contact in an emergency (who will be available during this retreat)
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Emergency Contact's Phone
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(###)
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In case of a medical emergency, if necessary may we consult with your medical doctor?
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Doctor Name
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Doctor's Phone Number
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(###)
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Are there any medical needs or mobility limitations we should know about?
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If yes, please describe?
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Are you currently seeing a therapist or psychiatrist?
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In case of an emergency, may we contact them?
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Therapist or psychiatrist's name?
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First Name
Last Name
Therapist or psychiatrist's phone number?
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(###)
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I give permission for my therapist to share information with Refuge Recovery World Services
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List dates (year) of previous retreats with this teacher or other teachers:
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Important: Participant interviews with teachers during retreats are purely for the purpose of supporting the participant’s meditation practice during the retreat and are not - nor should be they be construed as – a form of psychotherapy or counseling.
List any other meditation practices or spiritual traditions that you have been or are currently involved with (i.e. Zen, Dzogchen, Tibetan, etc.) and the approximate years you have practiced in this or these tradition(s).
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What motivates you to do a retreat at this time?
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What is your current daily / weekly spiritual / meditation practice?
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Do you have any condition or history of physical illness or physical limitations that may interfere with or might be aggravated by sitting or walking practice?
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Have you ever had or been treated for a psychological condition such as depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition? Please specify condition(s) and date(s):
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Are you currently taking medication for any physical or psychological conditions? If yes, please specify the condition and list the medications and dosage.
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Have you experienced any significant emotional, psychological or spiritual difficulty in your life (that affected your ability to function)? If so, please briefly describe it and when it occurred. Is it still occurring now?
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Have you ever attempted to take your life?
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If so, please state when:
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How does the practice of meditation, silence and retreat affect the above condition?
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Are there present conditions in your life which may be placing you under stress, or which might make meditation difficult for you at this time (e.g. fasting, recent loss of a loved one, substance abuse/withdrawal, relationship ending)?
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Are there any additional comments or information you would like to convey to the teacher(s)?
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