Since we were opened by the then Governor-General, Sir William Deane, in 1999 we have helped over 4,000 people throughout Australia.

In Western Australia we offer a five day residential program to help you heal from your childhood issues. It is run by trained survivors for survivors in peaceful rural surroundings. Carers and facilitators will help unlock the childhood trauma which you wish to address. If you feel that your childhood has had an effect on your current life today it's you we want to help.

Independent research has shown that 98% of guests found the program effective in helping them heal from childhood trauma.

Although it costs us over a thousand dollars for each person who attends at the adult centre we make the cost achievable and affordable to anyone no matter what their financial situation. We never refuse a guest on the basis of finances.

There are many forms of childhood trauma and abuse equally impacting on the development of the brain are such traumas as abandonment, neglect, death of a parent at a very young age, or serious childhood illness as well as sexual, physical, emotional and satanic ritual abuse.

Our carers and facilitators who will support you through the week have all been through some form of childhood trauma and now want to help others find healing. They have received extensive training so as to provide effective support.

The program includes workshops on Boundaries, Inner Child work, Attachment theory, and Effects of Trauma on the Brain, all of which help you understand why you act behave and feel the way you do and you also learn how you can change. Yes you can change because science has now proven that the brain can change, we provide the tools so that when you are triggered or suffer from the many impacts of child abuse or trauma such as flashbacks or nightmares you can process though this on your own.

The program is run in groups with a maximum number of twelve, however all our work is done independently and we do not share our stories in the group.

You may be experiencing one or several of these symptoms:

• Feeling unsafe at night
• Poor sleep patterns, nightmares
• Feelings of guilt, self-blame, shame
• Flashbacks
• Anxiety, depression
• Disconnection or co-dependency in relationships
• Low self-esteem
• Addictions to alcohol, drugs, sex, gambling, workaholism, obsessive spending, people pleasing
• Self harm, Eating disorders
• Trouble with the law

Adult Program Registration

THIS INFORMATION IS CONFIDENTIAL UNLESS DUTY OF CARE REQUIRES DISCLOSURE

*****Please do not make any work or travel arrangements before you receive confirmation from us.

Please fill up the form below. Fields marked with ( * ) are required.

• Personal Details
• General Info.
• Emergency
• Medical: Part 1
• Medical: Part 2
• Confirm and Submit

Personal Details

Date of program you wish to attend: *

No available date

Email Address: *

First Name: *

Last Name: *

Date of birth: *

Gender: *

Male

Female

Mobile:

Phone: *

Preferred method of contact: *

by Email

by Phone

by Mobile

All

Address: *

Town / Suburb: *

State: *

Post Code: *

General Information

Do you have children? *

Yes

No

If yes what ages? ( If many, separate age with a comma )

Are you of Aboriginal or Torres Strait Islander origin? *

Yes

No

Occupation: *

Is this your first healing program with Heal For Life? *

Yes

No

If no, was your program more than 3 months ago?

Yes

No

Has a member of your family done a healing week before? *

Yes

No

How did you find out about Heal For Life Foundation? *

Family / Friends

Television

Radio

Phone Book

Newspaper

Brochure

Seminar

Web Search

Social Media (eg. Facebook, Twitter, Instagram)

Organisation or Service Name:

How will you be arriving to attend your program?

Private Transport

Public Transport - Station

None of the above

Emergency Contact

Full name: *

Relationship: *

Mobile:

Phone: *

Medical: Part 1

Have you had a drug, alcohol, gambling issue? *

Yes

No

If yes, have you been clean for 30 days?

Yes

No

Addiction:

Alcohol

Gambling

Illicit drugs

Non-prescription Medication

Other

Yes

No

Have you been clean for 30 days?

Yes

No

Do you take any medications? *

Yes

No

If yes, please list all medications, dosages/times below: (Kindly separate each using a comma " , ")

Are you pregnant?

Yes

No

If yes, how many weeks?

Do you have any allergies or any specific dietary needs? *

Yes

No

If yes, please list: (Kindly separate each using a comma " , ")

Can you swim? *

Yes

No

Do you snore? (If yes, you may be asked to sleep in a more private area.) *

Yes

No

Do you have any Phobias/fears that you feel it would be best we know about? If none, please put N/A to the field.

If you feel it would be helpful for is to know, please note any physical impairments, medical conditions, mental illness or eating disorders you have been diagnosed with: e.g. asthma, diabetes, epilepsy, bipolar, DID, PTSD, etc. If none, please put N/A to the field.

Medical: Part 2

To enable us to help you better you may wish to let us know the type of trauma you are a survivor of: *

Physical

Emotional

Sexual

Spiritual

Neglect

SRA

Poor Parenting

Bullying

Abandonment

Incest

Domestic Violence

Early Childhood Illness

Divorce of Parent / Sibling

Death of Parent / Sibling

Other: e.g.war, refugee, natural disasters, medical emergency, etc.

We have a list of health professionals around Australia that previous guests have recommended; would you like to refer yours to other survivors?

Yes

No

To be referred to a:

Counsellor

Psychologist

Psychiatrist

First Name:

Last Name:

Mobile:

Landline:

Address:

Town / Suburb:

State:

Postcode:

Is there anything else about your current circumstances that might be useful or helpful for us to know? If none, please put N/A to the field.

Please note down what your goals might be for the week, eg, what would you like to change about yourself or your life by attending the program? If none, please put N/A to the field.

If Heal For Life leaves a phone message for you, would you prefer the name “Heal For Life” not be mentioned?

Yes

No

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What does it cost to attend the 5-day Adult Healing Week?

The following fee covers 5 nights’ accommodation and all workshops during the program, we wish to keep our program as affordable as possible, we trust you will opt to pay the fee that meets your financial situation. To keep it simple we will buy the weekly groceries for your meals. The cost is $50.00. Please advise if you have any special dietary requirements.

Please select the following:

Payment Method:

Full upfront payment

Cheque

Option 1: Full Upfront Payment - $1000

We require the Initial Registration Fee to be paid at the time of Registration. You can pay this directly into our account:

NAB
Heal for Life Foundation (WA) Inc
086-554 18-586-9465

Please mark your payment with: ACC + your name
e.g. ACC Jane Smith

Once we have received your payment and registration details, we can confirm your place in the program.

Option 2: Cheque

If you would like to pay by cheque or money order (payable to Heal For Life WA) please forward to:

P O Box 924 Bunbury 6230

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Cancellation / Deferral:

We often have a wait list for our programs. IF you cancel, defer, or do not come to a confirmed place, this may prevent someone else from attending. For this reason, please tick that you have read and understood the following:

I accept that if I cancel or defer after confirmation has been received, HFL will retain an administration fee of $150 from any monies I have paid;

If I cancel/defer within 7 days of the program start date I understand that I am committed to complete the payment option I have chosen;

If I do not attend the program I have confirmed booking for, I understand that I am committed to complete the payment option I have chosen;

If I choose to leave the program prior to its completion I understand that I am committed to complete the payment option I have chosen;

If I am asked to leave the program I understand that I am committed to complete the payment option I have chosen.

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