By submitting this application, I am stating that:

I am a Virginia resident.
The information in this application is complete and accurate to the best of my knowledge.
I am available to travel on these dates and I am able to fully participate in the program activities.
I understand completion of this application does not guarantee a scholarship or acceptance into the retreat.
I understand that a cancellation within 14 days of program start date or a no-show will forfeit my scholarship eligibility for 1 year.
I understand that this is essential for my acceptance into a Mental Health Virginia training.

Name

First

Last

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Are you a crime or trauma survivor?

Yes
No

Are you a peer recovery specialist?

Yes
No

Do you have a service dog?

Yes, I do
No, I do not

Is your service dog required because of a disability?

Yes
No

What work or task has the dog been trained to perform?

Please let us know about any physical limitations, dietary restrictions and/or food allergies.

Emergency Contact Full Name

First

Last

Emergency Contact Phone

Program Readiness

Please assess your readiness to fully participate in the (Re)STORE: Retreat by answering the following questions:

Have you previously attended?

(Re)STORE: Sampler (90 min webinar)
(Re)STORE: Essentials (4 hr virtual training)
(Re)STORE: Retreat (2 day training)
None, I have not attended any of these

Do you have the stamina to participate in a full day of activities?

Yes
No

Are you able to work collaboratively with others in small groups?

Yes
No

Are there any issues that would prevent you from learning at this time?

Yes
No

Are you ready and able to travel independently?

Yes
No

Background & Experience

How do you see this retreat impacting your own life and relationships?

Please describe how you relate to others with different backgrounds, cultures and viewpoints. Please give a thoughtful example.

Please describe what you would like to contribute to the mental health community and how you would like to influence opportunities for people working towards recovery.

Describe an activity you have been involved in that demonstrates your commitment and follow through.

What is your greatest challenge in attending and participating in the retreat and how will you address that challenge?

How did you hear about this event?

If other, where did you hear about (Re)STORE?

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(Re)STORE: Retreat