The EVENT Registration

Name:

Email:

Phone:

Other trainings/workshops you’ve attended:


What’s going on in your life right now that made you decide to participate in The Event?

Are you currently in psychotherapy? yes no

If so, what form:

If in therapy, do you agree to advise your therapist that you will be attending The Event? yes no

Do you regularly use alcohol or social drugs? yes no

Have you ever been in a residential treatment program for alcohol or drug use? yes no

*Important: I agree not to consume any alcohol or social drugs the days of The Event Training from 10am Friday through the completion of the Sunday night session. yes no

Have you ever been hospitalized or under care for a mental disorder or suicide attempt, or has
such hospitalization ever been recommended to you by a mental health professional?   yes no
If so, please describe

Have you recently been under a doctor’s care for any condition whatsoever? yes no

If so, please describe:

Do you have a history of  physically violent behavior? yes no
If so, please describe:


Please describe any physical conditions we should be aware of:

Do you have any communicable diseases?  yes no

Are you presently using any prescribed medication?  yes no

If so, please describe:

*Important: I agree not to reduce my dosage or stop taking any prescription drug prior to or during the training. 
yes no

Are you pregnant? yes no

Comments:

Thank you!!
Peacemaker Institute