Long Island Center for Mindfulness
What is Mindfulness?
Benson House Retreat Questionnaire
Thank you for filling out this questionnaire. I realize the personal nature of some of these questions. Please be assured that the completed forms are kept in strict confidence. I, Cory Muscara, am the only person who sees this information. Any information you are willing to provide will be of great help to me in assisting you with common issues that may arise during the retreat and for us to best accommodate your housing arrangements. No record of this questionnaire, other than contact information, will be kept after the course is completed.
Indicates required field
How did you hear about this retreat? If referred by a health care provider, friend, or family member, please provide his/her name.
Any current significant medical problems?
Any current significant psychological problems?
Any dietary restrictions? e.g. vegetarian, gluten-free, allergies, etc.
The following questions will help us best accommodate you within the Benson House
Do you wish to room with any person(s) during this retreat? If so, please list their name(s)
Do you snore?
Do you smoke?
How do you identify your gender?
Transgender or gender diverse (e.g. gender queer, gender fluid, agender, etc.)
Which would be your preferred accommodation?
Room for men
Room for women
Please also indicate any mobility or other limitations, or needs we should be aware of in assigning your room and having you on retreat with us
Is there anything else you would like me to know?
Informed Consent Agreement
I understand that if for any reason I am unable to, or think it unwise to engage in any of the techniques and exercises discussed and presented during this retreat at Camp DeWolfe, I am under no obligation to engage in these techniques nor will I hold the above named facility or its instructor liable for any injury incurred from these practices.
By choosing "Yes," you agree to the above informed consent agreement.
Once you hit Submit, you will be redirected to the checkout Page where you can
proceed with payment to complete your registration.
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