Registration Intake Form FGTG

"From Guilt to Grace" Welcome Letter
We offer weekend retreats for men and women who have experienced abortion and have suffered the aftermath it causes, including guilt, shame, anger, remorse, and grief. The retreat weekend is a journey From Guilt to Grace.

During the retreat, we will focus on God's abundant grace that removes our guilt and shame. We will do this by focusing heavily on God's living word that transforms our hearts and minds.

Many of us on the team have also experienced the aftermath of abortion, but we have found great freedom by fully embracing and trusting the finished work of Christ on the cross. You too can be set free!

We want to assure you that you will not be alone on this journey. We will be walking alongside you, and more importantly, your Heavenly Father will be with you every step of the way, gently guiding you and healing the broken places within your heart.

Our retreats are open to both men and women. The men and women will be together during the teaching sessions, but will be separated during the breakout sessions.

When we receive your completed and signed Registration Intake Form and payment, you will be considered registered.

Prior to attending the retreat, we will send you a confirmation packet with details about the retreat weekend. Please don’t hesitate to contact us with any questions or concerns.

It will take some thought and some time to complete this form, so we recommend you complete it when you have time and are not feeling rushed.

** Many of the questions below will require a response before you can proceed to the next question, so if the question does not apply to you, please put N/A or Does not apply, or something applicable in the box.
Registration Intake Form
Today's Date*

MonthDayYear
Date
Dates of desired retreat*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip
Email Address*

Confirmation Emailexample@example.com
Phone*
Age
Sex*

MaleFemale
What is your marital status?*

MarriedSingleSeparatedDivorcedWidowed
If you are married, is your spouse aware of your abortion(s)?*

YesNoNot applicable
Do you have any living children?*

YesNo
If yes, how many living children?
What do you hope to gain from attending this retreat?*
How do you feel about attending this retreat?*
It is normal to have some trepidation or fear about attending an abortion healing retreat. If applicable, what is your biggest fear about attending this retreat?*
Have you attended other post-abortion Bible studies or retreats?*

YesNo
If yes, how long ago?
Have you ever sought counseling for your abortion(s)?*

YesNo
If yes, how long ago?
Do you consider yourself to be a Christian?*

YesNo
How long have you been a Christian?*
How does someone become a Christian*
Are you currently affiliated with a church?*

YesNo
Where do you attend church?*
What is the denomination?*
How would you describe your Bible knowledge?*

ExtensiveModerateLimitedNo knowledge
Abortion History
It is not uncommon for women or men to have experienced more than one abortion.

I, Karen Reynoso, the Founder and Director of the ministry, have experienced four (4) abortions. I hope this fact helps you feel safe to share your abortion history.

Below, please provide as much information as you can for each abortion. We understand that it is not always easy to remember the details, so just do the best you can.
WOMEN: How many abortions have you had?*
MEN: How many abortions have you participated in or have knowledge of?*
First Abortion
Year of abortion*
Your age at the time of the abortion*
Marital status at time of the abortion*
How many weeks were you pregnant?*
Type of abortion*

Chemical pillSuctionD&ESalineOther
What was the reason for the abortion?*
Are you still in a relationship with this person?*

YesNo
If yes, are you married to them?*
Did you feel pressured to have the abortion or did you choose? Please explain:*
* If you have had one abortion, you can skip down to "Symptons of Abortion."

* If you have had more than one abortion, please proceed to Second Abortion.
Second Abortion
Year of abortion
Your age at the time of the abortion
Marital status at time of the abortion
How many weeks were you pregnant?
Type of abortion

Chemical pillSuctionD&ESalineOther
What was the reason for the abortion?
Are you still in a relationship with this person?

YesNo
If yes, are you married to them?
Did you feel pressured to have the abortion or did you choose? Please explain:
* If you have had two abortions, you can skip down to "Symptons of Abortion."

* If you have had more than two abortions, please proceed to Third Abortion.
Third Abortion
Year of abortion
Your age at the time of the abortion
Marital status at time of the abortion
How many weeks were you pregnant?
Type of abortion

Chemical pillSuctionD&ESalineOther
What was the reason for the abortion?
Are you still in a relationship with this person?

YesNo
If yes, are you married to them?
Did you feel pressured to have the abortion or did you choose? Please explain:
* If you have had three abortions, you can skip down to "Symptons of Abortion."

* If you have had more than three abortions, please proceed to Fourth Abortion.
Fourth Abortion
Year of abortion
Your age at the time of the abortion
Marital status at time of the abortion
How many weeks were you pregnant?
Type of abortion

Chemical pillSuctionD&ESalineOther
What was the reason for the abortion?
Are you still in a relationship with this person?

YesNo
If yes, are you married to them?
Did you feel pressured to have the abortion or did you choose? Please explain:
* If you have had four abortions, you can skip down to "Symptons of Abortion."

* If you have had more than four abortions, please proceed to Additonal Abortions.
Additional Abortions
If you have experienced additional abortions, please list general information here.
Symptoms of Abortion
Below is a list of some symptoms men and women experience after abortion. Check each of the symptoms you have experienced since your abortion(s), whether past or current.*

GuiltAnxietyFlashbacksShamePanic attacksSleep disturbancesFearSuicidal ideationMarital stressAngerFeeling inferiorSexual problemsResentmentFeeling unworthyInfertilityBitternessFeeling helplessFear of infertilitySadness / SorrowFeeling hopelessFear of pregnancyLonelinessSelf-loathingAlcohol / Drug abuseGrief / LossSelf-hatredEating disordersEmotionally numbSelf-sabotagingPromiscuityDepressionSelf-mutilationFear God's retributionCrying spellsNightmaresFear God won't forgive you
List any additional symptoms not listed above
Which symptoms are the most problematic for you currently?*
On a scale of 1 to 10, where are you on your journey of healing from abortion?*

1

2

3

4

5

6

7

8

9

10

1 is Deep Pain, 10 is Complete Healing
Do you believe God has forgiven you for the abortion(s)?*

YesNo
If no, why not? If yes, briefly explain.*
Abortion is traumatic. Have you experienced additional trauma in your life?*

Sexual abuse or molestationRapeVerbal or mental abuseNeglect or abandonmentPhysical abuseNoAlcoholic or drug addicted parentOther
If yes, please briefly explain the traumatic event(s)
Have you been diagnosed with post-traumatic stress disorder (PTSD)?*
Are you currently under the care of a counselor, therapist, or psychiatrist?*

YesNo
** NOTE: If you are under the care of a counselor, therapist, or doctor, it is important that you inform them that you will be attending this retreat to address your abortion wound.
Are you currently taking medication for emotional issues or mental illness?*

YesNo
Do you have any food allergies? If so, please list them.*
How did you find us?

A friendFacebookOur websiteInstagramWeb searchOther
Emergency Contact Name*
Emergency Contact Phone Number*
WE ARE NOT LICENSED PROFESSIONAL COUNSELORS

Choosing Truth Team Members are peer volunteers and are not licensed professional counselors. Choosing Truth retreats are not intended to take the place of professional counseling or treatment.

By signing below, you are acknowledging the fact that we are not licensed professional counselors and that we are lay Christians with a desire to lead participants back to the truth of God’s Word.
CANCELLATION POLICY

If you find that you are unable to attend the retreat, full refunds are available up to two weeks prior to the retreat. Refunds are not available if you cancel within two weeks of the retreat.
I have read and agree to the cancellation terms above*

YES
Printed Name*
Signature*

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"From Guilt to Grace" Welcome Letter

Registration Intake Form

Abortion History

First Abortion

Second Abortion

Third Abortion

Fourth Abortion

Additional Abortions

Symptoms of Abortion