About Us
Individual, Couples, and Families PIVOT Coaching
PIVOT Glass House Retreat
PIVOT Academy
PIVOT Tribe
HealthyAdult Book
Get Started Now
Blog
Shop
Testimonials
Contact Us

1-855-452-0707

Glass House Registration

Please fill out the following for your Glass House Retreat.
Upon receiving and approving your registration, you will be notified and directed to payment and travel arrangements.
When your full payment is verified and confirmed, your registration will be complete.

Hidden
Current Page URL
Name*
First Name Last Name
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Age?*
Are you currently employed?*
- No
- Yes
If so, who do you work for and what do you do?*
How Did You Hear About Us?*
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
- Couples Personalized Intensive
- Individual Personalized Intensive
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
Do you have any allergies?
- Yes
- No
Allergies
Please Explain
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 - Our retreats are non-refundable. In the rare event and due to circumstances out of our control, we reserve the right to cancel and reschedule your original retreat.*
- I Accept the Cancellation Policy
Transfer Policy - If you wish to transfer to a different date, you may do so as long as it is 30 days before your original start date. There is a $250 processing fee to complete the transfer.*
- I Accept the Transfer Policy
Email
This field is for validation purposes and should be left unchanged.

© 2021 Lori Jean Glass, LLC | PIVOT