Breastrest retreat Survivor Application Desired BreastRest Retreat Community * 6/20/24 - 6/23/24 8/22/24 - 8/25/24 (TNBC in DMV) 11/7/24 - 11/10/24 Name * First Name Last Name Email * Social Media Handles Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Age of Diagnosis * Date of Diagnosis * Last Day of Treatment * Type of Breast Cancer * What was going on in your life at the time of diagnosis? * What was your treatment regimen? (please include all chemotherapy, radiation, and surgeries) * Did you have any complications during these treatments? Please explain. * What was your support system like during treatment? What is your support system like post treatment? * Do you have a mental health history? If so, please describe your diagnoses, their symptoms, and necessary medications. * Describe 3 physical challenges that you have struggled with during survivorship. * Describe 3 mental/emotional challenges that you have struggled with during survivorship. * Describe 3 relational/intrapersonal challenges that you have struggled with during survivorship. * At this time, I am… (check all that apply) * Menopausal Struggling with intimacy with my partner Having painful sex or no sex at all Taking a hormone blocker (i.e. Tamoxofin, Letrozole) Tolerating side effects from my medications well Feeling alone in survivorship Seeing a therapist Crying randomly Having bouts of anxiety Feeling depressed Hating the way I look naked Hating the way I look in clothes Struggling with chemo brain More positive than negative More negative than positive Group dynamics are important to consider when planning a retreat like this. The goal is to create a safe, supportive, and welcoming space for every Boobie Queen that decides to share pieces of herself with the group. In order to do that, The Boobie Queen Company is very intentional in creating each retreat community by assessing commonalities between applicants as well as what effect each applicant might have on the group. For example, we wouldn’t create a retreat with 1 introvert and 7 extraverts. We also wouldn’t create a retreat for 7 women who did not have children and 1 who did. Connection would be more difficult in these scenarios. Furthermore, the next set of questions are a way for us to get to know you so we can best serve you by matching you with the right people. There are NO right or wrong answers. How would your best friend describe you? * If single, are you dating? Why or why not? If applicable, describe your relationship with your partner during survivorship. If applicable, describe your relationship with your kids during survivorship. If applicable, describe your relationship with your family during survivorship. What is your enneagram number? If you don’t know, you can take a free test here. What is your Myers-Briggs Personality Type? If you don’t know, you can take a free test here. Are you introverted or extraverted or a little bit of both? Please explain. * How well are you at taking care of yourself mentally and physically? * How do YOU like to be pampered? * Thank you for your application!
