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Pre-retreat Mental Health Questionnaire

7-Day Mindfulness Meditation Retreat - Denenkamp, Jan. 8th - 14th, 2023

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Question 1 of 7

Please Enter Your:
1. Name
2. Email address
3. Tel. Number (with country code)

Question 2 of 7

Briefly describe your past meditation retreat experience:
How many retreats?
What meditation method?
Silent or not?
How many days?
Or "none".

Question 3 of 7

Have you ever, or do you currently have any mental health concerns? If yes, please describe. 

Question 4 of 7

Have you ever, or are you currently taking anti-depressants and/ or any other mental health-related medication? If yes, briefly describe. 

Question 5 of 7

Have you ever, or do you currently have any substance dependency? If yes, briefly describe. 

Question 6 of 7

Do you suffer from PTSD (Post-traumatic stress disorder)? If yes, briefly describe. 

Question 7 of 7

Please note that confidentiality will be respected as per Western medical standards and this questionnaire will be kept private and secure.

 

I hereby declare that all answers disclosed above are accurate to the best of my knowledge. I also understand that the organizers of the 7-day meditation retreat at Zusters van Denenkanp monastery will not have responsibility for any omissions in this questionnaire.

(Select all that apply)
A

Yes, I agree.

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