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Heart of Recovery Retreat Participant Survey
Karmê Chöling: August 2019
Due to the length and depth of the Heart of Recovery Retreat it is necessary that participants have a stable foundation in their recovery. We suggest 3 months active recovery as the minimum for participation. This survey is an opportunity for us to learn more about you and where you are on your path of recovery. You will be contacted with a registration code to register online once we have reviewed your application and contacted you, if necessary.
Please know that whatever is shared here will be confidential.
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Last Name
Your answer
First Name
Your answer
Email address
Your answer
Phone number
Your answer
Please describe your relationship to addiction and recovery: What is the primary substance or behavior of your addiction (this includes adult children of addicts, parents, siblings, or spouses of addicts)?
Your answer
What are the elements of your recovery (Outpatient/inpatient rehab, AA, working with a recovery coach, Refuge Recovery, Smart Recovery, etc)?
Your answer
How long have you been in recovery?
Your answer
Meditation Experience
While prior meditation experience is not a prerequisite for this program, it is helpful for us to know what background participants have with meditation practice(s).
This will be my first experience of meditating
Yes
No
Clear selection
If you have experience with meditation, please describe the type of meditation you have practiced, how long you have practiced, and how regularly you practice.
Your answer
If you have experience with yoga, tai chi, or other contemplative practices, please describe.
Your answer
What do you aspire to work on during this retreat?
Your answer
Is there anything else you'd like us to know?
Your answer
Are you familiar with Heart of Recovery?
Yes
No
Clear selection
I understand that any retreat environment can be challenging in nature and will take full responsibility to continue any prescription drug medications I am currently taking.
please check the box if you agree
agree
disagree
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