Chetana Lauren Barkan - Tao of Gratitude | Trauma Release for Women Retreat Application
Thank you for taking the time to answer the below questions. We sincerely understand the potential sensitivity & vulnerability in facing this process.
Chetana Lauren Barkan, Trauma Release for Women, Tao of Gratitude, Trauma Retreat, Trauma Conference, Healing Event, Training, Breath, Apply, Application, Sign up, Attend
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Thank you so much for your interest in joining a Tao of Gratitude retreat

Thank you for taking the time to answer the below questions.

We sincerely understand the potential sensitivity & vulnerability in facing this process. This information is valuable for knowing and understanding you better, which enables an educated determination about your participation in the group retreats and/or individual retreats.

I strive to offer the most appropriate and best possible care & support for you. Please answer honestly.

This application is strictly confidential and will be reviewed by the Tao of Gratitude team only.

    What retreat are you applying for?

    Personal Information

     

     

     

     

     

    What is your knowledge of the English language?

     

    Please share why you are interested to attend this retreat

     

    Medical History

    Are you currently seeing either a Psychologist or a Psychiatrist OR have you seen one in the past? YesNo 
    If yes, please provide the details of the nature for this care.
    For what specific purpose? For how long? The results?
    Any other relevant information:


     

    Have you ever been hospitalized for psychiatric care? YesNo 
    If yes, please provide the details of the nature for your hospitalization.
    For what specific purpose? For how long? The results?
    Any other relevant information:


     

    Are you currently taking or have taken psychiatric medications? YesNo 
    If so, please share which prescriptions, for what diagnosis, for how long and the results:


     

    Are you currently under the care of a medical doctor? YesNo 
    If so, please provide the details of the nature for this care:


     

    Are you currently taking any medications? YesNo 
    If so, please list the names and what for.
    For example: blood pressure, anti-seizure, asthmatic or COP inhaler


     

    Do you currently have or have been diagnosed with any communicable diseases? YesNo 
    If so, please tell us which disease you have been diagnosed.
    What are or have been the treatment protocols? The results?


     

    Please select how you found us:
     

    Is there any additional information you feel to share?
    Is there anything we could benefit from knowing that isn't included in the application?




    Please Submit your application.
    We will review and respond within the next 72 hours!
    Looking forward to meeting you!