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Individual Healing Retreat Health and Registration Form

Individual Healing Retreat Registration Form

Which retreat would you like to attend?

Diagnosis and Treatment

Which stage?
Have you had any recurrence?
Have you received chemotherapy?
Are you currently receiving chemotherapy treatment?
Have you received radiation?
Are you currently receiving radiation treatment?
How do you feel physically?
Have you been fully vaccinated for COVID-19?

Roommate Request & Consent

Do you snore?
Are you a light sleeper?
Please check the box as your photo consent below: " I hereby grant to Bluebird Cancer Retreats its agent or assigns, my permission to use my first name, any and all pictures, photographs of or news stories about me for reproduction in any form for, but not limited to, advertising, illustration, television, or scientific publication."

Health and Holistic Therapy Questionnaire

As part of your retreat experience, emotional and physical pampering opportunities may be available. The following information will be given to volunteer practitioners and our staff for your protection and to allow them to best serve you. This is required for all attendees.

Has your doctor warned you against having deep tissue massage or other body work?
Do you have a history of blood clots?
Have you tried any alternative forms of therapy during your cancer journey? (Massage, healing touch, chiropractic, etc.)

Consent for Therapy

Please type the date and your signature below after you read the consent for holistic therapy.

Emotional Care Questionnaire

Are you currently in a cancer support group?
Do you feel you are receiving enough support in your life currently?

Please hit submit and wait to receive an email or call confirmation. We primarily serve local West Michigan residents first, then open up our offerings to other locations. Thank you!

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