Personal Information:

First name:

Last name:

Birthday:

Gender:

Phone

Email:

Emergency Contact:

Background Information:

What are your primary reasons for attending this EMDR retreat?

Have you previously participated in any therapy or counselling? If yes, please provide details (type of therapy, duration, etc.).

Are you currently working with a therapist or counsellor? If yes, please provide their name and contact information.

Have you ever been diagnosed with a mental health condition? If yes, please specify the diagnosis and treatment received.

Have you experienced any significant trauma or life events that you feel are relevant to share?

Are you currently taking any medication? If yes, please list them and the conditions they are prescribed for.

Do you have any history of substance abuse? If yes, please provide details (substances used, duration, treatment received).

Do you have any medical conditions that we should be aware of? Please provide details

Have you had any recent surgeries or hospitalisations? If yes, please provide details.

Do you have any allergies (medication, food, environmental)? Please list them

Are you currently pregnant or trying to conceive?

Do you have any physical limitations or disabilities that may require accommodation during the retreat?

On a scale of 1 to 10, how would you rate your current level of stress or anxiety?

Short ans Have you experienced any recent changes in mood, behavior, or thoughts that concern you?wer

Are you currently experiencing any thoughts of self-harm or suicide? If yes, please provide details.

Do you have a support system in place (family, friends, support groups)? Please describe.

Have you previously participated in EMDR therapy? If yes, please provide details (duration, frequency, outcomes).

How would you describe your experience with EMDR therapy?

What are your expectations for this EMDR Intensive?

Do you have any dietary restrictions or preferences (e.g., vegetarian, vegan, gluten-free, etc.)?

Are there any specific dietary needs or preferences we should be aware of for meal planning?

Is there anything else you would like us to know to help make your retreat experience more comfortable and beneficial?

How did you hear about this EMDR retreat?

I consent to participate in this EMDR retreat and agree to the terms and conditions provided.

I acknowledge that I have provided accurate and complete information to the best of my knowledge.

Signature

Date