Name
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First Name
Last Name
Age
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Email
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Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Language
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How did you hear about Wild Heart Ministries?
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Pregnancy Centre
My Church
Google
Friend/Relative
Social Media
Other
What led you to register for our retreat?
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Emergency Contact
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First Name
Last Name
Emergency Phone Number
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(###)
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Relationship Status
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Single
Married
Separated
Divorced
Common Law
Other
Are you currently affiliated with a religious organization?
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If so, what faith/organization/church?
Describe your faith and spiritual beliefs?
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How strongly do you adhere to your faith and spiritual beliefs?
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Is there a central figure in your spiritual beliefs?
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If so, describe your relationship with your faith's central figure.
Tell me about your relationship with Jesus or what is your understanding of Jesus?
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How does your faith/spiritual belief system view abortion? What do they teach about abortion?
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How does your faith/spiritual belief system view and deal with emotions, grief, and truama?
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What does your faith/spiritual belief system teach about forgiveness?
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Are you comfortable being placed in a group of women who many have a different faith than one that you believe in?
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If no, please explain why.
How many abortions have you had?
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Approximate date(s) of your abortion(s)
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Your age when you had your abortion(s)?
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How many weeks pregnant were you?
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What type of abortion(s) did you have?
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Was/were your abortion(s) performed in a hospital or clinic?
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If you knew the father of you baby, what did he think about the pregnancy?
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Do you know where he is now? Do you have contact with him?
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Was there anyone else that knew about you pregnancy?
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Did anyone help you make the decision to have an abortion?
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Did you feel pressured to have the abortion?
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Have you spoken to anyone about your abortion experience(s)?
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Please check the box if you are currently struggling with any of these symptoms/issues AND they are related to your abortion(s)
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What is the most difficult emotion from your abortion(s) that you are currently dealing with?
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How do you feel you life has changed since your abortion(s)?
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Have you already sought help for the pain connected to your abortion(s)? If yes, please explain.
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If you have any children now, how would you describe your relationship with them?
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Describe any experiences you have had with support/recovery groups. How do you feel about group settings?
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What emotional support do you currently have in place as you consider attending post abortion recovery?
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Are you currently pregnant?
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Describe your emotional and/or physical health today as it relates to your abortion(s).
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List all the substances you have used in the last year and the frequency of the use.
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Have you ever had psychiatric medication prescribed and/or been hospitalized in an effort to treat symptoms you have experienced?
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If yes, please provide details.
Are you presently involved in counselling and/or support groups?
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If yes, please provide details.
Do you have any food allergies?
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Please select the retreat date you are interested in.
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The retreat is run by two leaders. One has a history of abortion and the other does not. How do you feel about this?
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On the scale of 1-10, how strongly do you want healing from the pain of your abortion(s)
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Where would you like to see the greatest change in your life after you attend this retreat?
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How are you feeling about attending this weekend retreat and sharing within a group setting?
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Is there anything else you would like us to know?
