Temp Form | Kinder in the Keys

Trauma Retreat Form

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Step 1 of 7 - Personal Information

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Name*

First Last

Email*

Phone*

What interests you about the 12-day retreat?*

What goals would you like to achieve by attending the retreat?*

Are you able to step away from your daily life responsibilities for 12-days?*

Have you attended any retreats in the past?*

Where did you attend the retreat?*

This retreat focuses on Taking Your Power Back and trauma, what trauma will you focus on during the retreat?*

What is a good word to describe your personality?*

How do you handle conflict?*

What have you done for yourself in the last 2-3 weeks?*

What coping skills do you use regularly? What coping skills are you interested in learning?*

How does your trauma hold you back? *

Are you comfortable with sharing a bedroom/bathroom with another person(s)?*

What excites you about sharing accommodations with 5 other women?*

Do you enjoy outdoor activities like nature walks, yoga, paddleboarding, and boating?*

Do you have any physical limitations?*

Do you need handicap accessible accommodations?*

Please elaborate on your physical limitations

Kinder is an alcohol and drug free facility, are you comfortable refraining from all substances, including alcohol during the 12- day retreat?*

Are you currently taking any medications?*

Are you able to manage your own medications?*

What medications and how long have you been taking them?*

Have you been admitted into any treatment centers in the past?*

Where? What levels of care? (Detox, Residential, Partial Hospitalization, Intensive Outpatient? When were you admitted?*

Have you had any suicidal thoughts in the past or currently?*

Do you experience crying spells, panic attacks, or difficulties sleeping?

Have you had any homicidal thoughts in the past or currently?*

A digital detox is part of the Kinder process, are you comfortable having limited access to cell phones, tablets, and computers during the 12- day retreat?*

Kinder provides nutrition options that are organic and NON-GMO. Our 12 day retreat refrains from serving processed foods, soda, gluten free foods, and foods high in sugar. Are you comfortable following a clean eating menu throughout the retreat?*