TheInstituteforRelationalHarmReductionPublicPathologyEducation
CLIENTSELF-ASSESSMENT-RETREATS
Note:Pleasebesureyouarereadyandabletoattendtheretreat/1:1beforeyousubmityourapplication.Checkthatyou:
- knowtheretreatdates
- cangettimeofffromworkandotherresponsibilitiestoattendtheretreat
- havecheckedonchildcare
- havethefundstodothis
Weareasmallstaff;processingretreatapplicationseatsachunkfromourlimitedtime.
Thanksforyourhelp!
Today’sDate:Whatisthenameoftheretreatyouwanttoattend?
Whichretreatdatesareyouinterestedin?
Name:
Address:
City: / ST / ZIP:
PhoneNumberIncluding:
TimeZone:
Email:
BestTimetoCall:
DOB: / Age:
Employer:
NumberofChildrenandtheirages:
MENTALMEDICALHEALTHQUESTIONS
Pleaselistthemedicationyouarecurrentlyonorwereoninthepast12monthsandwhattheywereprescribedfor:
Pleaselistpreviouspsychiatricmedicationsyouhavebeenonduringyourlifeandwhattheywereprescribedfor:
Haveyoueverbeenincounseling(inpatientoroutpatient)? Howlongandforwhatcondition?
Areyoucurrentlyseeingatherapist?Ifso,whatisthename,city,andphonenumberofyourtherapist:
Haveyoudiscussedthisretreatwithyourcounselor?Whataretheirfeelingsifyouareinaplacetodothisrightnow?
Haveyoubeendiagnosedwithanymedicalconditions?
Haveyoubeendiagnosedanytimeinyourlifewithanyemotionalormentaldisorders?
Doyousmokecigarettes/howmuch:
Drink/howmuch:
Userecreationaldrugs/howmuch:
HaveyoueverbeeninSubstanceAbuseTreatmentincluding12Steps?
Howlonghaveyouused?
Howlonghaveyoubeensober?
EntrapmentScale
Entrapmentreferstoawomanbeing ‘stuck’ inherrelationshipbecauseshecontinuestofeelinvestedintherelationshipbecauseofhowmuchtimeshehasputintoit,howwellhehascometoknowher,andsharedexperiencesandrelationshipsthatwouldbelostiftherelationshipended.
Iwantasafeandcommittedrelationshipmorethananything
Ihaveputalotintothisrelationship(time,self,love,etc.)
Duringviolence/roughtimesintherelationship,Idoubtthat
Iwilleverhaveasafeandcommittedrelationship
IwanttoleavebutIfeelconflictedbetweenloveandfear
SometimesIfeellikeIhavesomecontrolintherelationship
Morethannot,Ifeelhelplessaboutthedirectionoftherelationship
Ilackaccessibledaycare
Ilackjobskillsthatcansupportme/kids
Ilackcurrentavailablemoneytoleave
IlackaplacetogoifIleave
Total
RESILIENCYFACTORS
Thesearepositivethingsinawoman’slifethatcanhelppreventherfromchoosingchronicallydangerousmen.
Ihaveoverallgoodphysicalandpsychologicalhealth
Ihavegoodcopingskillstohandlemystress
Idonothaveasubstanceabuseproblems
IdonothaveahistoryofviolenceinmyfamilywhileIwasgrowingup
IdidnotwitnessviolencewhenIwasachild
Myfamilyisveryclose
Myfamilyisflexibleandcanhandlewhenthingsgowronginoneofourlives
Myfamilyissupportive
Ihaveothersupportivepeopleinmylifeaswell
Ihaveagoodsociallife
TOTAL
RiskFactors
Ihaddivorcedparents
Ihaveboutsofdepression
Ihavelowselfesteem
Igrewupwitnessingorexperiencingabuseinmyfamily
Igrewtobelievethisishowfamily’sbehaved
Myabusenowislessthantheabusemymotherhad
Mydadwastheonlyonewhohadpowerinthefamily
Mymotherneverchallengedhispower
Mymomwasoppressedinhermarriage
Idon’tfighttheoppressioninmyrelationship
Mymothersubmittedtomyfathernomatterwhat
Ifeeloverlycommittedtomyabusiverelationship
Themorehebetraysme,themorelovinghecanbe
Themorelovingheis,themoreIfeelconnectedtohim
Icomefromorcurrentlyhavealowsocio-economiclevel
Idon’thavealotoffriendsorfamilysupport
Ineedvalidationfrommyrelationshiptofeelgoodaboutmyself
Idon’tfeelgoodaboutmyselfwhenIamnotinarelationship
Itendtoonlyseethegoodinourrelationship
IknowIamdependentonhim
Itendtotakecareofothersfirst
WhenIwasachild,Itookcareofadultsandmysiblings
IwasexpectedtotakecareofadultswhenIwasachild
Other’sneedsalwayscamefirstwhenIwasgrowingup
Iamattractedtomenwithproblems
Ihavebeenwithmorethanone ‘needy’ man
Itrytomakemenfeelgoodaboutthemselvesiftheyhavelowself
esteem
Itrytorescuehimfromhisbadchoices
IwasaparenttomyparentswhenIwasgrowingup
Ifeelmoreconnectedtomymanwhenhesharesthebadthings
abouthislifeorchildhoodafterwefight
WhenmylifeisreallymessedupIlookmoreoftentomyrelation-
shipforcomfort
Iprobablywouldnotleavemyrelationshipifmylifewasreally
messedupinotherways
Ilet/hopemyrelationshipwillsolvemymesseduplifeproblems
Themoretheotherpartsofmylifearemessedup,themoreIfeel
connectedtotherelationship
Whenmylifeisnotgoingwellinotherareas,Itendtominimize
howbadmyrelationshipiswithhim
Whenmylifeisnotgoingwell,Itendtominimizetheseverityof
violenceIexperiencedwithhim
Whenmylifeisnotgoingwell,Itendtothinkitwasprobablymyfaultthattherelationshipisn’tgoingwell.Iblamemenothisbehavior
RightbeforeIstartedinthisrelationship,mylifewasamess
RightbeforeIstartedthisrelationship,Ifeltisolatedfrommyfamily/friends,hadnomoney,wasevictedorhadnoplacetostay,justendedanotherrelationship,justlostmyjob,orwaspregnant
Ioftenfeelpressured(byfamilyorsociety)tobeinaseriousrelationshipthatisgoing ‘somewhere’
IoftenfeelpressuredthatIshouldbemarriedbynow
IamafraidifIendthisrelationshipIwon’tfindanyoneelse
MybiologicalclockistickingandIneedtohavechildrensoon
TOTAL
CurrentSymptoms
CurrentSymptomsthatyouareexperiencingorhaveexperiencedoverthepastsixmonthsorlonger:
Depression(depressedmorethanIamnotdepressed)
Haveorhadsuicidalthoughts
Haveorhadsuicidalplans
Havemadesuicidalgestures(overdosing,cutting,etc.)
Anxiety(consistantorcomesandgoes)
Flashbacks:Ifyes,howfrequent:
IntrusiveThoughts:Ifyes,howfrequent:
Actorfeellikeeventsfromtherelationshiparehappeningnow
Intenseemotionalreactionatexposuretosomethingthatremindsyouoftherelationship/violence
Sweatingorotherphysiologicalreactionswhenexposedtosomethingthatremindyouoftherelationship/violence
Avoidthoughts,feelingsorconversationsabouttherelationship/violence
Avoidactivities,places,peoplethatarouserecollections
Inabilitytorecallimportantaspectsoftherelationship/violence
Diminishedinterestinsignificantactivities
Feelingdetachmentemotionallyfromothers
Restrictedrangeoffeelings(feelnumb)
Worrythatyourfuturewillbeshortened(yourcareer,lifeandchildrenslives)
Difficultlyfallingorstayingasleep
Irritabilityoroutburstsofanger
Difficultyconcentrating
HyperVigilant
Exaggeratedstartleresponse
Difficultyconcentrating
ADDorADHDlikesymptoms
Losetrackoftime(minutes,hoursorevenlongercangobyandyoudon’tknowwhatyouhavebeendoing
Difficultystayingpresent
Havearrivedsomeplaceordonesomethingwithnoremembranceofit(excludingtimesofusingalcohol,meds,ordrugs).
Youhavebecomemoreemotionally,verballyorphysicallyviolent(towardsobjectsorothers)
Youhaveorarecurrentlyover-usingalcohol
Youhaveorarecurrentlyover-usingstreetdrugs
Youhaveorarecurrentlyover-usingprescribedmedications
Feelpanickedatthethoughtofbeingalone
Havebeenaccusedof/ordoyouhaveabandonmentissues
Allofyourrelationshipsseemtobeintenseandoftenunstable
Youtendtoidealizeothersbuteventuallydevaluethem
Yourselfimageisunstableandyoutendtoseeyourselfthruhowotherstellyou,youare
Areimpulsiveinanyofthefollowingareas:pleasecheck:
___Spending___Sex___SubstanceUse___Recklessdriving___bingeeating
Youfeelchronicallyempty
Youhavedifficultycontrollinganger
Youbecomeparanoidwhenreallystressedorseemtodissociatealot
Youhaveorhadaneatingdisorder
Youovereat
Youundereat
Youbinge
Yourpurge(withfingerorproducts)
Youhaveorfearyouhaveasexualaddiction
Yoursexualbehavioriscurrentlyoutofcontrol
Relationships
Areyoucurrentlywiththepathological/personalitydisorderedpartner?Ifno,howlonghaveyoubeenapart:
Howlongwereyouwiththelastpartner?
Howmanyotherpathologicalpartnersdoyouthinkyouhad?
Wereyouparentspathological,ifso,whatdoyoususpecttheyhad?
Whatisthelongestamountoftimeyouwerenotinarelationship?
Areyoucurrentlyseeingsomeone?
Functionality
Howmanyhoursadayareyououtofbed,offthecouchoroutoftherecliner?
Doyouwork,ifsohowmanyhoursperweek?
Haveyoubeenfiredorde-motedduetoproblemsinfunctioninginyourjob?
Areyoucurrentlyongovernmentassistanceofanykind?Ifso,whattypes:
Howmanyhoursadaydoyousleep?
Howmanytimesadaydoyoueat?
Areyougettinganyexerciseperweek?Ifso,whatandhowlong?
Recovery
Whathaveyouusedtotrytohealfromthisrelationship?
Whathasworkedbest?
Whatisn’tworking?
Whatareyounotwillingtodoinordertoheal?
WhatInstituteitemshaveyourread?
CurrentSymptomsCONTINUED
Whatdoyouwanttoworkonattheretreat?
Whatdoyouhopeyouaccomplishattheretreat?
Pleasedescribe,in2or3paragraphs,yourcurrentpathologicalmansituationandyourpasthistorywithanyotherpathologicalmen.
SpecificsAbouttheRetreat
Thisretreat is being held in the Asheville/Brevard NC area, the Land of the Waterfalls in the beautiful Blue Ridge Mountains.
Accommodations
We are renting vacation homes for the retreat which consists of shared bedrooms, baths, living, dining room, kitchen and lovely outdoor space. Each house varies by square footage and decorations.
The downtown area of Brevard is rated as one of the top 10 great small towns in the U.S. And consistently voted as one of the best places in AARP. In the area we have the Pisgah National Forest, the Dupont Forest and Holmes Educational Forest. There are 250 waterfalls in the county and over 500 hiking trails. We will make time for outings to the forest recreationally while you are here (weather permitting).
TheAPPROXIMATEformatis:
9:00a.m.Groupsessions
12:30-1:30pm...... Lunch
1:30-4:30pmGroupsessions
Someeveningsarefree,somearegroupoutings,somewemayhaveeveningsessionsdependingonhowfarwegetinthematerialeachday.
Ifyoudrive,youarewelcometogo out the evenings we do not have events or sessions.
(Wereservetherighttoadjusttheformatasneededforstafforotherreasons.)
Airports
Weprovidecomplimentaryairportpickup/dropoffto Asheville, NC airport ONLY.
Ifyouflyintoanyotherairportyouwillneedtorentacarasotherairportsarenotwithinconvenientdrivingdistanceforus.
Cost
Theretreat,approximately20hoursofgroupsessions,airportpickupanddropoff,andaccommodationsare$635forasharedroom. We do not keep a list for those seeking to attend only if they have a private room. In some cases there are no private rooms. Weaskforyourflexibilityonthisastravelarrangingisnotourprimaryjobfocus.Foodisnotincluded in the cost.Wewilltakeyoutothegroceryonarrivaldateifyouareflyingin. And we can also go by the store on days we are out for recreation.
RegistrationProcess
Tobeconsideredforthisintimateretreat,filloutthispacketofinfo.Insomecases,wemayaskthatyoufilloutfurtherquestionnairesbutwewillnotifyyouifweneedmoreinformation.
Emailyourpacketbacktous.Itwillbereviewedandyouwillbenotifiedifwefeellikeyouarereadyandappropriateforthislevelof psycho-educational retreat.
Onceyouareacceptedintotheretreat,yourpaymentwillbedue.
Payment
Paymentisdueinfulluponacceptance.Topay,youcanuseyourcreditcardorcheckthroughourPayPalsystem.We are only set up for payment through Pay Pal.
RetreatFocus
EachretreatfocusislistedonourwebsiteunderRetreatDescriptions.
Prerequisite
Read ‘HowtoSpotaDangerousMan’ bookandworkbookandWomenWhoLovePsychopathsbook. Please bringanotebookorjournaltowritein.
Sorry,nochildren,otherfamilymembersorpets.Smokingispermittedoutsideonly.
Return this completed form to saferelationships (at) yahoo.com.
Please read our refund policy about retreats listed on the website.
We look forward to your healing time here with us.
The Institute for Relational Harm Reduction
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ClientSelfAssessment-Retreats
LastUpdate:4/8/2011