Retreat Intake Form

Name

Address

Phone

Email

Age

Date of Birth

Website

Marital Status

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Occupation

Emergency Contact

Place of Employment

Emergency Contact Phone(s) and Email

Because we want you to feel welcome and at home, please list your favorite foods (snacks, fruits, vegetables) and beverages so that we may stock your room for your arrival:

What is your preferred hot or cold beverage? (i.e. your favorite "Starbucks" order)

Background

How long have you been working in ministry and what positions have you held?

What motivated you to seek this retreat? (What needs help or attention?)

On a scale from 1-10, how serious do you consider this matter to be?

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On a scale from 1-10, how optimistic are you that it can be improved or resolved?

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On a scale from 1-10, how motivated are you to do what you can to improve or resolve it?

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What are you hoping to gain from this retreat? (List as many things as you’d like)

What Christian denomination/theology do you resonate with most closely?

What personal and family history are important to consider for our conversations? (e.g. history of addictions, adoptions, abuse, divorce, depression, expectations, etc.)

What health or other personal issues, if any, are important to consider during our time together? (Please also list any food allergies for us to respect during your stay.)

Where I am Today

(1 = not at all/10 = extremely)

Tired

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Overwhelmed

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Strained

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Stress

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Foggy

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Stuck

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In transition

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Content

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Clear-minded

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Motivated

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Happy

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Understood

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Discouraged

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Misunderstood

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Anxious

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Burned-out

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Guilty

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Defeated

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Hopeful

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Rested

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Filled

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Reflective

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Confident

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Ready

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Confused

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Depleted

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Despairing

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Hurt

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Alone

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Distant

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Curious

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Connected

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Encouraged

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Unhurried

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Trusting

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Questioning

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Exhausted

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Frustrated

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Busy

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Disconnected

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Done/spent

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Inspired

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Free

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Focused

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Thankful

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Renewed

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Peaceful

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Understanding

I/we understand that I am responsible for the choices I make and the consequences that follow and that The Coffman Company is not held liable for those choices.

I/we understand that everything I/we say is confidential unless I/we are considered to be a physical threat to myself or another or unless unreported abuse has occurred (as required to report by law).

I/we understand the fee charged for the retreat and will cooperate with our agreement.

I/we understand that Joey Coffman has an MDiv in Pastoral Counseling and Robyn Coffman has a Masters in Marriage and Family Therapy. They are certified under the BCPPC (Board of Christian Professional and Pastoral Counselors), and are not licensed by the state of Arizona.

I/we understand that Joey and Robyn Coffman counsel from a Biblical perspective.

CONTACT US

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