Name:

Address:

Phone:

Email:

Year of birth:

Year of HIV+ diagnosis:

Gender:

Total income from all sources:

Amount that you can afford to pay for the retreat*:

Sexual orientation:             

Do you have any disabilities or medical conditions that we should be aware of?

Have you ever been the victim of sexual or physical abuse? If so, please describe the circumstances and dates when the abuse occurred. Is this a current problem in your life?

Do you have a history of alcohol abuse or drug use? If so, please describe the extent of it and when this occurred. Is this a current problem in your life?

What are some of the issues that you are dealing with in your life now that you think that the retreat may help you with?

Have you ever been diagnosed with a mental illness? If so, please describe. Is this a current problem in your life?

Some of the work that we do at the retreat can be emotionally challenging. Do you understand that you are responsible for your own mental, emotional and physical well-being while you are at the retreat?

 

Send your completed answers to brotherhoodretreats@yahoo.com.

*We do not offer full scholarships that cover 100% of the cost so you need to be able to pay something.