Retreat Yourself

take a Retreat in the comfort of your home

Our ReTreat Yourself program allows you to be a part of a Respite Retreat in the safety and comfort of your home. We will deliver a box full of items and activities designed to help you take time for self-care and relaxation. Please complete the form below to sign up.

Recipients must be within 6 months of active treatment or the caregiver of a patient within 6 months of active treatment to be eligible for this program.

ReTreat Yourself Gift Boxes may take up to 2 weeks to arrive.

I understand that Respite Retreats programs are for cancer patients, their families & caregivers with a current cancer diagnosis or within 6 months of active treatment.

I am a cancer patient, caregiver or family member of someone with a current cancer diagnosis.

I am a cancer patient, caregiver or family member of someone within 6 months of cancer treatment.

PATIENT'S NAME

First Name

Last Name

PATIENT'S AGE

PATIENT'S GENDER

ETHNICITY

ADDRESS

CITY

STATE

ZIP CODE

COUNTY

PATIENT'S PHONE

(###)

###

####

PATIENT'S EMAIL

TYPE OF CANCER & STAGE

TREATING HOSPITAL

ONCOLOGIST OR TREATING DOCTORS NAME

PHONE

I give Respite Retreats permission to contact my healthcare provider listed above with any questions concerning my diagnosis.

Yes

No - This will not disqualify you from receiving a ReTreat Yourself Gift, however, may require a submittal of a letter from your treating doctor with information pertaining to your diagnosis.

PATIENT IS

NAME OF PERSON RECIEVING THIS RETREAT YOURSELF GIFT BOX

Please add name & shipping address if different from the patient's address above.

PERSON RECEIVING THIS GIFT IS

NAME & CONTACT INFORMATION OF PERSON COMPLETING THIS FORM

ALLERGIES

Please list any allergies or sensitivities here and be sure to check ingredients on all body products in your ReTreat Yourself Gift Box prior to use. Please note - We do not send food items.

NOTE:

How did you hear about us?

FOR HOSPITAL PERSONNEL ONLY

I have gifted this person a ReTreat Yourself Gift

Please mail this person a Retreat Yourself Gift

If you are interested in participating in a Virtual Retreat, please visit https://respiteretreats.org/virtual-retreats for more information.

If you are interested in receiving stuffed animals for your children through Bryanna’s Love, a Respite Retreats partner, please visit http://bryannaslove.org/Family-Support/ and fill out the form at the bottom of the page.