Alumni Men's Retreat Application

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Phone

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Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

Relationship Status*

Children*

Profession*

SI:LA Dates of Attendance*

Sobriety Date*

Emergency Contact*

Do You Have Any Medical Issues?*

Yes

No

What Medical Issues Do You Have?

Do You Have a CPAP Machine?*

Yes

No

Do You Have Any Dietary Restrictions?*

Yes

No

What Are Your Dietary Restrictions?

Who is Your Therapist?*

How Often Do You See This Therapist?*

What Are You Currently Working On?*

What 12-Step Meetings to You Typically Attend?*

Do You Have a 12-Step Sponsor?*

What Step(s) Are You Currently Working?*

What Are Your Goals for This Retreat?*

What Weaknesses Do You Want to Work On?*

What Strengths Do You Bring to the Table?*

Speak with a Seeking Integrity Staff Member Regarding Treatment. Call 1-747-234-4325