Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

We collect this information to follow up with you if we have any questions about registration or payment.

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Have you discussed your family wounds with a counselor, priest, or a trusted friend? *

We believe our retreat is a great complement to counseling, spiritual direction, and/or ongoing conversation with trusted friends. Knowing this information helps us to best serve you during the retreat.

Yes

No

Do you feel emotionally and psychologically capable at this time to attend an event where strong emotional content about family life will be discussed, shared, and processed? *

If you are seeing a counselor or psychologist, then please consult first with him or her about whether he or she believes it is a good time for you to attend a retreat like this one.

Yes