Ecotherapy for Helping Professionals Retreat Registration Questionnaire

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* 1. All answers to this survey are confidential and will only be shared with the facilitation team for the purposes of customizing the retreat. We understand you are busy and welcome your brief and specific answers, in order to give you the best experience. Thank you!

I have read the confidentiality statement for this questionnaire.

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* 2. Please enter your contact information, including license or registration title, if applicable.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. Payment method, amount, and date

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* 4. Do you have any accessibility challenges we should be aware of? If so, please explain so we can make this event as inclusive as possible.

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* 5. What is your specific field of service and how long have you been in this field?

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* 6. Describe your client or patient load and population, as well as the primary focus of your practice.

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* 7. If you are the partner of a helping professional, please state their name and field, and how long you have been with them.

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* 8. What drew you to the retreat and what is your ideal outcome for the day?

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* 9. Please identify one thing you would like to let go of and one thing you would like to receive in the course of the retreat.

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* 10. Please add any comments or questions here.