Retreat Intake Form

This form helps us design your retreat around you — your season of life, your vocation, your hopes, and your limits.   

Please answer as openly as you are comfortable; there are no required disclosures here, and everything you share is held in confidence by our facilitation team.

Section 1: About You

First name

Last name

Email

Phone

Address

Date of birth

Month

Day

Year

Emergency Contact (name, relationship, phone):

Section 2: Vocation & Season of Service

This retreat is designed for those who carry the burdens of others — pastors, ministry leaders, healthcare workers, missionaries, social workers, and other compassion-driven professionals.

Current Vocation/Role:

Years in this vocation:

Years in current role:

Name of Employer/Church/Organization:

Briefly describe the demands of your current season - what does a typical week ask of you?

Have you taken an extended rest (sabbatical, leave, retreat) before? What was that like?

Section 3: Why are you coming?

What is bringing you to this retreat in this season? What has been accumulating in your life that helped make the decision to attend?

If this retreat does what you hope, what will be different when you return home?

Section 4: Spiritual Life

Retreat at Annandale is ecumenical, meaning we welcome the breadth of Christian tradition. These questions help us shape worship, prayer, and spiritual direction in ways that feel more like home to you.

Church denomination/Faith tradition (if any):

Which spiritual practices are life-giving to you right now (e.g., Scripture, silence, liturgy, worship, nature, journaling)? Which feel difficult or distant?

Experience with one-on-one spiritual direction:

Currently meet with a spiritual director

Have in the past

Never, but open to it

Prefer not to include spiritual direction

Where do you sense God in this season - or where does God feel absent?

Section 5: Wellbeing & Care

The Retreat at Annandale practices trauma-informed care. Share only what you wish; what you do share helps us pace the retreat well and avoid what would not serve you.

How is your sleep?

Current stress level

Counseling or Therapy

I am currently working with a counselor or therapist

I have worked with one in the past but not currently

I have never worked with a counselor or therapist

Is there any history - loss, trauma, burnout, health - you would like our team to be aware of as we design your retreat time?

Are there topics, practices, or experiences that have negatively affected you in the past that we should avoid?

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Our retreats provide rest and renewal, but are not a substitute for acute medical or psychiatric care. If you are currently experiencing a mental health crisis or thoughts of harming yourself, please tell us so we can talk with you before the retreat about whether this is the right setting and timing for you, and help you connect with the right level of care.

I would like to talk with someone about this before the retreat

Section 6: Designing your retreat

Rate your interest in different retreat elements:

Extended silence and solitude

High

Medium

Low

No interest

One-on-one spiritual direction

High

Medium

Low

No interest

Shared meals and community conversations

High

Medium

Low

No interest

Time on the land - walking trails, creek, wildlife

High

Medium

Low

No interest

Somatic/emobodied practices (breathing, stretching, rest for the nervous system)

High

Medium

Low

No interest

Scripture reflection and guided prayer

High

Medium

Low

No interest

Creative practices (journaling, art, etc.)

High

Medium

Low

No interest

Theological or ecological inquiry/learning

High

Medium

Low

No interest

Note any physical limitations that may affect walking, hiking, or activity:

Any dietary needs or restrictions?

Any lodging or accessibility needs?

Is there anything else that would make this retreat restful for you, or anything that you think might ruin it?

I understand that the information on this form will be shared only with the Retreat at Annandale facilitation team for the purpose of designing and leading my retreat, and that this retreat offers spiritual and restorative care, not medical, psychiatric, or licensed counseling treatment.

I declare that the information I’ve provided is accurate and complete.

Electronic Signature