Welcome!

Welcome to the Redeemed Hope Intensive Healing Retreat. We are so glad you have registered and decided to make this step into your next chapter of healing. Please take some time to complete the intake form. This form is held confidential and will only be used to serve you and your needs better. If this form misses a detail that you need to share please feel free to contact Lyschel Burket at support@hoperedefined.org.
Name(Required)
Birth Date(Required)
Address
Which retreat will you be attending?(Required)
Current Marital Status(Required)
Does your husband (ex) know you are attending this retreat?(Required)
Do you have children?(Required)

Personal Health Inventory

In this section, you will share your personal health inventory.  We ask these specific questions to ensure quality of care for each participant at the retreat.
Are you currently taking any medications or supplements to address this mental illness?(Required)
* If you are currently taking any medication please DO NOT stop taking unless directed by your health care provider.
Are you currently working with a coach/therapeutic/licensed professional?(Required)
IMPORTANT: Please complete a Release Of Information form for your professional.

Recovery Work

In this section we would like to learn about the recovery work done so far. We will ask you to share both your personal recovery work and your husband's.
Are YOU currently or in the past: (check all that apply)(Required)
Is HE currently or in the past: (check all that apply)(Required)

More Info

Dietary Needs(Required)
Please share any dietary needs that you have while we serve you this weekend. (allergies, avoidance)
Emergency Contact Name(Required)
Please provide the name of an emergency contact we may use while you're at the retreat.
Relationship with Emergency Contact(Required)
This will allow us to "see" you when we pray for you before we meet you face-to-face.
Max. file size: 64 MB.
Clear Signature
Date of Submission

Contact Us

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