Family Intake Form

We love getting to know the families interested in taking this journey with us! Please fell out the following info, which helps us provide a tailored experience and get a feel for if we believe our retreat will be beneficial for your family.

Parent Names (one or both)

Name of Children

Address

City

State

Telephone

More Family Details

Birthdates (please list of each family member)

Emergency Contact Name

Emerg. Contact Phone

Emerg. Contact Email

Parent Occupations

Family Statistics (children, married/unmarried, etc)

Family Hobbies and Additional Interests

Intentions and Experience

What is your intention for signing up for this retreat? Have you done something like this before?

What do you hope to gain from this experience?

Where would you and your family like more clarity in your life?

Parent Personal Growth

Please describe any current practice or belief that is related to your personal growth.

Please list any training or healing modalities, that you have participated in that have guided you on your personal growth journey.

What are your hobbies and interests?

Children Growth and Development

Please describe your children’s growth and development up to this point in their lives.

Family Health History

Please tell us about your families physical health (list any major illnesses, surgeries, any pervious injurious or physical conditions that may impact your well-being)

List any allergies or medications

Has any family member ever been diagnosed with a mental health disorder? Past or Present?

Does any family member have current psychotherapy, counseling or psychiatric treatment? Please describe:

More About the Children

As parents, how would you best describe your children? (please list each individually)

What are their personal strengths as seen through your eyes? (please list each individually)

What (if any) challenges are they experiencing through your eyes? (please list each individually)

What are your children’s hobbies and interests?

Relationships

Please share with us your relationship as parents:

Please share with us your relationship with your kids:

Please share with us the relationship your kids have together:

Adventure

Please describe each family members swimming ability:

Does anyone in the family experience sea sickness on a boat?

Travel

Has your family traveled together internationally before?

Does each family member have a passport?

Food

Does any family member have food restrictions or allergies? If yes, please describe in detail

Client Consent

I attest that I and my family are in sound physical and mental health to participate in the Family Reset Retreat with Jill Ryan and Jake Roussos. I acknowledge that this experience may bring to the surface memories, sensations and emotions that show up so that I am able to process them and repattern their significance in my life and support my family along the way. I am fully responsible for myself and my well-being and accept all responsibility of my actions and choices on my path towards wellness. I understand that it is my responsibility to communicate all questions and concerns to Jill or Jake as appropriate. The relationship of my experience will be held in confidential boundaries, unless my safety is a concern.