Register for Roots Retreat Women's Workshop

Roots Retreat Women's Workshop Registration

Please complete the form below to register for the Roots Retreat Women's Workshop.

Roots Retreat Date (select the weekend you plan to attend)*

May 16-17, 2025

Personal Info

Name*

First Last

Email*

Phone

Address*

Street Address City State ZIP Code

Birthdate*

Marital Status*

How did you hear about the Roots Retreat?*

Name of person who referred you...

If you selected "Other," how did you hear about it?

Have you ever attended a recovery or support group?*

Yes
No

Have you ever attended a recovery event/workshop of this type?*

Yes
No

What was the intensive you attended, and approximately when did you attend?*

Are you comfortable sharing openly in a group setting?*

Yes
No

Have you been diagnosed with any of the following (check all that apply)?*

Bipolar Disorder
Borderline Personality Disorder
Psychotic episodes (seeing or hearing things that are not real)
Other diagnoses (please describe below)
No diagnosed issues

If you selected "Other diagnoses," please describe it/them here.

Have you had life experiences (additional to partner sexual betrayal) you would describe as traumatic?*

Yes
No

Have you experienced suicidal thoughts?*

Never
Have in the past
Am currently experiencing

If you are currently experiencing suicidal thoughts, PLEASE immediately call the Suicide Prevention Hotline at 1-800-273-8255.

Have you ever attempted suicide?*

Yes
No

If you have attempted suicide, please give the approximate date.*

Have you ever been hospitalized for mental illness?*

Yes
No

If you have been hospitalized for mental illness, please give the approximate date.*

Are you currently on any medication(s) for psychological or emotional reasons?*

Yes
No

Please list current medication(s) and condition(s)*

Do you have any dietary restrictions or allergies?*

Yes
No

Please describe any dietary restrictions or allergies you have.*

Are you currently working with a therapist, counselor, or life/recovery coach?*

Yes
No

What is your therapist/counselor/coach's name?*

What is your therapist/counselor/coach's contact info?*

Do we have your permission to contact your therapist/counselor/coach regarding your registration for the Roots Retreat?*

Yes
No

He/she will not be permitted to acknowledge you are a client or give us any info unless you give them written authorization to communicate with us.

By checking this box, I authorize Awaken to communicate with me using the information I have provided.*

I agree

By checking this box, I agree to hold Awaken harmless for any external breach of my personal information (website hack, etc.). I understand Awaken will keep collected information secure and will keep my personal information confidential to the best of their ability, and will only share such info with Roots Retreat professional staff.*

I agree

Payment Info

If you would like information on potential financial assistance for the Roots Retreat, please visit https://awakenrecovery.com/grantapplication.

Payment Amount*

A deposit is required to complete your application process. Please select payment from one of the options below. (If your application is not approved, your payment will be refunded.)

Roots Retreat Deposit ($100)
Roots Retreat Pay In Full ($500)

Enter Amount

Total

$0.00

Credit Card

Card Details

Cardholder Name

Name

This field is for validation purposes and should be left unchanged.