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An Invitation to Healing - Program Application
This form does not allow you to save your progress, so we recommend completing in one sitting or writing your answers in a word document and pasting them into this form below.
For a complete list of questions, or to fill out this application in Microsoft Word, click here:
https://smithcenter.org/wp-content/uploads/An-Invitation-to-Healing-Program-Application-Google-Forms.docx
If you choose to fill out the application via Microsoft Word, please email the completed form to
retreats@smithcenter.org
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* Indicates required question
Email
*
Your email
Please list date(s) of 6-week online program you are interested in attending.
*
Upcoming Program Dates: May 17th - June 23rd, 2022
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Cell Phone Number
*
Your answer
Home Phone Number
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Emergency Contact Person
*
Name
Your answer
Emergency Contact Person - Relationship to Participant
*
Your answer
Emergency Contact Person - Phone Number
*
Your answer
Emergency Contact Person - Email Address
*
Your answer
Occupation or brief work history
Your answer
I am currently working:
Full-time
Part-time
Not working
Retired
Other:
Clear selection
Age
Your answer
Birthdate
Your answer
Current marital status:
Married/Partnered
Widowed
Divorced
Single/Never Married
Clear selection
Ages of children (if any):
Your answer
Are you presently under the care of an oncologist?
Yes
No
Other:
Clear selection
Please provide the name of your Oncologist or primary medical doctor.
Your answer
Please provide the phone number(s) for your Oncologist or primary medical doctor.
Your answer
Approximate date of initial diagnosis:
Your answer
Please provide your cancer diagnosis (including type of cancer and stage, if known):
Your answer
Do you have any metastases? (If yes, please be specific.)
Your answer
Have you had a recurrence?
No
Yes
Clear selection
If yes, when?
Your answer
Are you currently receiving treatment for your cancer?
No
Yes
Clear selection
If yes, please describe:
Your answer
Do you have any physical conditions - related to your cancer, cancer treatment or other health conditions - that would affect your ability to fully participate?
Yes
No
Not Sure
Other:
Clear selection
Are you currently taking medication for pain, depression or other conditions?
No
Yes
Clear selection
If yes, please describe:
Your answer
What types, if any, complementary/adjunctive therapies have you used in the past or are you currently using?
Your answer
Please list the current areas of greatest stress in your life presently (e.g., cancer therapy, relationships, work, finances, etc.):
Your answer
Are you currently seeing a psychiatrist, psychologist or other counselor?
No
Yes
Clear selection
If yes, please indicate your start date and any diagnosis received (if applicable):
Your answer
What has been the hardest part of your cancer journey?
Your answer
What are the major sources of support or nurture in your life?
Your answer
Do you currently feel that this level of support is sufficient?
Yes
No
Maybe
Other:
Clear selection
How did you learn about the 6-week healing program?
Your answer
What are your reasons for wanting to participate in the 6-week healing program?
Your answer
Do you have any concerns or fears about participating in this program? If so, please explain.
Your answer
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