Register

Join us today!


The first step to secure your place at an upcoming retreat is to fill out the questionnaire below. Once we have confirmed your acceptance, a $300 deposit is submitted. The balance is paid the first evening or before, if you prefer.

Please let us know if you have any questions or concerns.

PAYMENT METHODS

Pay your deposit through our PayPal system (2% surcharge applies).

To pay a deposit or full payment by check, please send payment to:

Healing for the Nations
3205 N Twyman Rd
Independence, MO 64058

To pay with a credit card (3% surcharge applies), call 1 (800) 483-2841

Click here to download our Microsoft Word version of the questionnaire. Type your responses, save your changes, open an email to hfnoffice@gmail.com and click on “Paste”, and then send.

If you have difficulty, please call us at 1 (800) 483-2841.

Healing for the Nations has the right to deny acceptance of anyone if after prayerful consideration we don’t believe the retreat is the best next step for that individual. In addition, while in most cases we will explain our decision, we are not obligated to do so.


Online Retreat Candidate Questionnaire

Choose Your 2017 Retreat Date

November 9-14

Choose Your 2018 Retreat Date

Jan 12-17Feb 16-21March 16-21April 27 - May 2June 1-6July 6-11Aug 10-15Sept 14-19Oct 19-24Nov 30 - Dec 5Not sure

PERSONAL HISTORY

Name:
Age:
Home Phone:
Business Phone:
Cell Phone:
Emergency Contact Phone:
Address:
City:
State/Province:
Zip Code/Postal Code:
Country:
Email:
Birthdate:
MaleFemale
SingleMarriedSeparatedDivorcedWidowed
Spouse's name (if married):

IF QUESTION DOES NOT APPLY, PLEASE TYPE "NA"

1. Please describe the reasons you would like to attend a retreat. Please include the struggles you are experiencing.

2.Have you had previous counseling/hospital treatment? If yes, please describe the type of counseling/hospitalization, when, and where. Would you describe this experience as helpful? If not, please explain.

BACKGROUND INFORMATION

3. Describe the relationships with the family you grew up with. How were problems resolved? Any history of abuse?

4. If not noted in your answer to question three, please share any major or traumatic events that you have experienced.

5. (If applicable) Is your marriage supportive? Please describe.

6. If you have children, please indicate their age(s), and living with whom.

7. With whom do you presently live and for how long? Are there any particular problems or difficulties in this situation? Please describe.

PHYSICAL INFORMATION

8. Please list all medications you are currently on if any. Prescription(s) and purpose(s).

9. Please check the following if applicable:
Heart Problems: PastCurrentNA
Comments:
Diabetes: PastCurrentNA
Comments:
Hypoglycemia: PastCurrentNA
Comments:
Epilepsy: PastCurrentNA
Comments:
Hepatitis A,B,C: PastCurrentNA
Comments:
Allergies: PastCurrentNA
Comments:
Other Issues: PastCurrentNA
Comments:

10. Are you currently under a physicians care for medical problems? If so, please explain.

11. Please list problems that we need to be aware of in order to properly care for you should a problem arise during the retreat. Include dietary allergies, etc...

12. In the past have you had a problem with alcohol or substance abuse? If so, how long ago and how was it addressed?

13. Please describe any learning disabilities or struggles that might interfere with your retreat experience.

EMPLOYMENT

14. What is your occupation? If you think it would be helpful please include any other employment history details.

RELIGIOUS AND SPIRITUAL INFLUENCES

15. Denominational preference and background.

16. Please describe any involvement in cults and/or the occult.

SUMMARY

17. What goals do you have regarding the outcome of the retreat?

SUBMISSION IS SUCCESSFUL WHEN THE SCREEN IS REFRESHED AND MESSAGE APPEARS UNDER SEND BUTTON