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Professional Partners
About Us
Our Approach
Our Programs
Our Target Client
Testimonials
Learn
Admissions
Upcoming Workshops
Registration
Payment
Travel
What to Bring
Contact
Connect With Us
Professional Partners
Transform Your Relationships
Connect With Us
Glass House - Registration Form
1. Please fill out the following to register for your Glass House Intensive. 2. Upon receiving and approving your registration, you will be notified and directed to payment and travel arrangements. 3. When your full payment is verified and confirmed, your registration will be complete. Your registration is not guaranteed until your full payment has been received and confirmed.
Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date of Birth
*
Date Format: MM slash DD slash YYYY
Age?
*
How Did You Hear About Us?
*
Therapist
Friend / Family Member
Internet
Other
Referral Name
First
Last
Referral - Phone #
Please describe where you heard about us
*
Have You Spoken to a Glass House Team Member?
*
Yes
No
Glass House Contact
Who did you speak with?
Upcoming Retreat You Are Interested In?
(choose all programs you are interested in)
5 Day - Women's Relational Repair and Restore Retreat
5 Day - Men's Relational Repair and Restore Retreat
Height
For accommodation purposes, please let us know how tall you are.
Interest
*
Please summarize why you are interested in coming to the Glass House.
Do you have a history of previous therapy, treatment centers or psychiatric hospitalization?
Yes
No
Previous Therapy
Please Explain
Are you currently seeing a therapist? If "yes," please share who it is below.
Yes
No
Current Therapist
May we contact your therapist? If yes, please list their name and phone number.
Are you currently working with a life coach or additional therapeutic support? If "yes," please share who/what it is below.
Yes
No
Other Therapeutic Support
Please list what other types of support you are utilizing, and/or the name of your life coach.
Existing Conditions
Please list any any pertinent medical conditions or mental health diagnoses.
Are you currently taking any medications?
Yes
No
Medications
Please list them with the prescribed amount.
Do you have a history of any suicidal thoughts or attempts?
Yes
No
Suicidal Thoughts
Please explain.
Have you experienced any physical, emotional, or sexual abuse as a child or adult?
Yes
No
Abuse
Please Explain
Are you experiencing any self-medicating behaviors? (Food, alcohol, drugs, nicotine, sex, gambling, etc.) If "yes," please share which ones and how often, below.
Yes
No
Self-medicating
Please Explain, which ones and how often:
Do you have any physical limitations?
Yes
No
Physical Limitations
Please explain.
Do you have any challenges with sleep? (Snore, Sleepwalk, etc.)
Yes
No
Sleep Challenges
Please Explain
Are you a recovering alcoholic or drug addict? if yes, please share how long you have been in recovery below.
Yes
No
How Long Have You Been in Recovery?
Do you attend any 12-step programs?
Yes
No
12-Step Programs
Which Ones?
Do you have a history of any eating disorders?
Yes
No
Eating Disorders
Please Explain
What would you like us to know about your relationship with food?
Do you have any allergies or medically necessary dietary restrictions?
Yes
No
Dietary Restrictions
Please Explain
What is your “Go-to Meal” for breakfast?
If you drink coffee, what do you take in it?
What is your married/partnership status?
*
Single
In a Committed Relationship
Married
Widowed
Divorced
Separated
Do you have any children?
Yes
No
Children
What are their ages?
What are your general hopes for your time with us?
*
Any questions or additional information that you would like to offer?
Cancellation Policy - For all programs, if a cancellation is made 2 weeks (14 days) prior to your program start date, we will offer a full refund with a $700 processing fee. If you cancel after the 14-day window, there is no refund. In the rare event and due to circumstances out of our control, we reserve the right to cancel and reschedule your retreat within three months or less from the date of your original retreat.
*
I Accept the Cancellation Policy
Transfer Policy - For all programs, if you wish to transfer to a different program, you may do so as long as it is before the 14-day cancellation window. There will be a $250 processing fee applied.
*
I Accept the Transfer Policy
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