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Retreat Questionnaire for Peaceful Warrior Rising Healing Retreats

Thank you for taking the time to complete this questionnaire. At Peaceful Warrior Rising, we want to create a retreat experience that is safe, supportive, and beneficial for every participant. This questionnaire helps us better understand your interest in attending, your goals for the retreat, and any emotional, physical, or personal considerations that may help us determine whether this experience is the right fit at this time. Because our retreats are designed as shared community healing experiences, honest answers help us support you with greater care and compassion.

Please know that your well-being is our priority. The information you provide will be reviewed with respect and sensitivity as we work to ensure that each participant is entering the retreat environment with the support they need.

We appreciate your openness and your willingness to take this important first step toward healing.

Please answer each question as honestly and thoroughly as you feel comfortable. Your responses help us determine readiness, support participant safety, and create a retreat environment rooted in trust, healing, and care.

First name

Last name

Phone

1. Where were you on the morning of 9/11?

2. How would you describe the impact of 9/11 on your mental, emotional and spiritual health?

3. Does the impact of 9/11 currently influence your life? If yes, please describe.

4. Why are you interested in this retreat?

5. What are you hoping to get out of this retreat?

6. Please share about your counseling or therapy experience related to 9/11. What type(s)? What, if any was most effective? What was least effective?

7. Are you currently seeing a therapist or psychiatrist now? If yes, is it related to the emotional impact from 9/11?

8. Have you had a psychiatric hospitalization within the last 5 years?

Yes

9. Any self-harming or aggressive behavior towards yourself or others or suicidal ideations within the last 5 years?

Yes

10. Are you currently or regularly taking prescription medication, recreational drugs, alcohol, illegal substances or plant medicine? If yes, what did you use most recently, how often and what is the reason?

11. Do you have any physical health issues you feel is important for us to know about?

12. Anything else you would like us to know about you? Questions, concerns or comments.

13. Are you willing to sign a liability form to in order to attend the retreat?

Yes

We collect identifiers (name, email, phone) and usage data to respond to your request and improve our services. We do not sell or share your data as defined by CPRA. See our Privacy Policy for details.

What Happens After You Submit

Once your questionnaire is submitted, our team will review your responses carefully and compassionately. We may follow up if we need additional information to better understand your needs, answer your questions, or determine whether this retreat is the best fit for you at this time. Our goal is to make sure each participant enters the retreat with clarity, support, and confidence.