Pre-admission

Pre-retreat admission questionnaire

This questionnaire is the first step to joining a retreat. Chris reviews every application personally and replies within 48 hours.

All the following information is kept in the strictest confidence and stored for 24 months before being deleted.

Thank you — Chris will review your answers personally and come back to you within 48 hours.

Before we begin: are you currently in active withdrawal or detox from any substance? *

Yes No

Thank you for telling us — your safety comes first.

Coming through withdrawal needs medical supervision, which we are not set up to provide on a retreat. Please speak to your doctor or your local addiction services first; they can help you do this safely.

We would still love to hear from you about a future retreat. Email us at chris.soloman@gmail.com or message us on WhatsApp at +212 718 670 773.

1Personal details

Full name *

Address *

Phone *

Email *

Date of birth *

You must be 18 or over to join a retreat.

Next of kin

Name *

Phone *

Your doctor

Doctor's name *

Practice and contact details *

2Problematic substance(s) or behaviour(s)

Please tick all that apply. *

Alcohol Cannabis Cocaine Prescription drugs (tranquilisers, sleeping pills etc.) Opiates Tobacco Pornography / sex Technology (internet, social media, gaming) Compulsive shopping Other

If other, please describe

3General health

Do you have any other mental health problems? *

If none, please write "None".

Do you have any physical health problems, disabilities or allergies? *

If none, please write "None".

What medication are you currently taking? *

If none, please write "None".

Have you ever been sectioned? *

Yes No

If yes, please tell us a little more (optional)

4Criminal convictions

Do you have any criminal convictions? *

This is not necessarily a barrier to the retreat but is a necessary safeguarding question.

Yes No

If yes, please tell us a little more (optional)

5Experience and expectations

What are your expectations for this retreat, and how will it add to your recovery? *

What previous experience do you have of therapy or recovery groups? *

What is your current relationship to your addictions? *

Trying to cut down Wanting to stop entirely Some success stopping, but I keep relapsing Sober for a length of time and wanting to stay that way

Anything you'd like to add? If you're in recovery, for how long? (optional)

6Group rules

Life in the group works because we all agree to a few simple rules:

Confidentiality — Group members can rely on, and will abide by, strict confidentiality.
Respect — For each other’s attempts to recover, for the staff, and for local customs in Morocco.
Presence — We agree to try and be fully present for ourselves and for group members in sessions.
Responsibility — For our behaviour on the retreat, abiding by local laws, and not doing anything to jeopardise the recovery of other group members.

I have read and agree to the group rules. *

7Commitments

Sobriety pledge. I agree to remain sober and free from addictive substances and behaviours for the duration of the retreat. I understand that if I do not, I will be asked to leave with no refund, to protect the group. *

In the spirit of Presence: Phone policy. I agree to hand in my phone during group work. My next of kin will be given Esperanza's contact details for emergencies, and my phone will be returned to me each day so I can talk to my loved ones. *

8Honesty declaration

I confirm the information given is truthful and complete. I understand that Esperanza Creative Recovery SARL AU accepts no responsibility for consequences arising from inaccurate or dishonest answers, and that dishonesty may lead to refusal or exclusion without refund. This form is governed by Moroccan law. *

9Your retreat

Which retreat(s) are you interested in? *

Trekking Music & Creative Surf Writing

Preferred dates (optional)

Website

Esperanza

creative recovery in Morocco

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chris.soloman@gmail.com
WhatsApp
+44 7872 376 351
Dar Souiri, Essaouira, Morocco

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