Tasmanian Teen Retreat

January 2018

To help us to support you on retreat, we need a few extra details. Please complete the questions below.

If you have any concerns or questions relating to this form don't hesitate to contact us!

e: grant@ime.org.au


Your Name *
Your Name
Emergency Contact Name
Emergency Contact Name
Emergency Contact Address *
Emergency Contact Address
Dietary and Medical Needs
As our retreats are fully catered it’s important we know about any special needs.
If yes, please provide details.
If yes, please provide details.
If yes, please provide details.
Additional Support
To ensure appropriate support for all teens on retreat it's important we know about any extra support you have received/or are receiving from mental health professionals.
Have you in the past or are you currently accessing counselling support through a Psychologist or Counsellor or other professional?
e.g. coping with stress, anxiety, low mood, drug or alcohol use, family or relationship issues. We understand this information may be sensitive and it will be treated confidentially*
If Applicable - Counsellor/ Psychologist details:
Celebrating diversity
This information will help us create an environment that supports every teen at the retreat. We realise these categories are limited, yet it will be helpful to us to know if you belong to any of the following:
Please check any that apply
More about you
Retreat Program Cost - We're commited to Accessibilty
E.g if you're family has an income of $30,000 per year, the cost will be $300. If it's $60,000, it will be $600. $100,000 - $900 etc.
Participants under the age of 18
Please indicate if you have recieved parental/ guardian consent to attend *