Bethesda Workshops 

a place for healing from sexual addiction in Nashville, TN

Registration

Healing for Men >

Healing for Women >

Healing for Partners >

Healing for Couples >

Healing for Wounds >

Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.



First Name:   Last Name:

I prefer to be called by:

Mailing Address:
City / State / Zip:

Preferred Phone:     Cell   Home   Work
Do you give Bethesda Workshops permission to leave a message?
    Yes   No

Alternative Phone:     Cell   Home   Work
Preferred E-mail address:

Birthdate:       Gender: Male   Female



Screening Questions

Your answers to any of the following questions do not automatically disqualify you from attending a workshop. If you mark "yes" to any question(s), Bethesda will contact you to be sure our workshop is the best fit, and your registration isn't final until after that's determined. If you have any "yes" answers, please wait to make travel arrangements.

Will this be your first experience being part of a therapeutic group?
    Yes   No

Do you anticipate having difficulty sharing as part of a small group?
    Yes   No


Please let us know if you've been diagnosed with any of the following:

Dissociative identity disorder (multiple personality)?
    Yes   No

Psychotic episode (seeing or hearing things that aren't real)?
    Yes   No

Bipolar disorder (manic depression)?
    Yes   No

Currently on or have been on medication for bipolar disorder?
    Yes   No

Is this medication effective?
    Yes   No

Borderline personality disorder?
    Yes   No

Experienced sucidal thoughts?
    Yes   No

Attempted suicide?
    Yes   No

If so, when?

Been hospitalized for mental or emotional health?
    Yes   No

If so, when?


Are you currently in counseling?
    Yes   No

Do you give Bethesda permission to contact your counselor?
    Yes   No

Have you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No

Counselor's Name       Counselor's Phone



Payment Options

$500.00 is minimal required deposit, which is non-refundable.
Full Payment  ($2,000.00)
Due Before Workshop  ($1,000.00)
Minimum Non-Refundable Deposit  ($500.00)


How did you hear about Bethesda?

Additional Comments:






Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



First Name:   Last Name:

I prefer to be called by:

Mailing Address:
City / State / Zip:

Preferred Phone:     Cell   Home   Work
Do you give Bethesda Workshops permission to leave a message?
    Yes   No

Alternative Phone:     Cell   Home   Work
Preferred E-mail address:

Birthdate:       Gender: Male   Female



Screening Questions

Your answers to any of the following questions do not automatically disqualify you from attending a workshop. If you mark "yes" to any question(s), Bethesda will contact you to be sure our workshop is the best fit, and your registration isn't final until after that's determined. If you have any "yes" answers, please wait to make travel arrangements.

Will this be your first experience being part of a therapeutic group?
    Yes   No

Do you anticipate having difficulty sharing as part of a small group?
    Yes   No


Please let us know if you've been diagnosed with any of the following:

Dissociative identity disorder (multiple personality)?
    Yes   No

Psychotic episode (seeing or hearing things that aren't real)?
    Yes   No

Bipolar disorder (manic depression)?
    Yes   No

Currently on or have been on medication for bipolar disorder?
    Yes   No

Is this medication effective?
    Yes   No

Borderline personality disorder?
    Yes   No

Experienced sucidal thoughts?
    Yes   No

Attempted suicide?
    Yes   No

If so, when?

Been hospitalized for mental or emotional health?
    Yes   No

If so, when?


Are you currently in counseling?
    Yes   No

Do you give Bethesda permission to contact your counselor?
    Yes   No

Have you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No

Counselor's Name       Counselor's Phone



Payment Options

$500.00 is minimal required deposit, which is non-refundable.
Full Payment  ($2,000.00)
Due Before Workshop  ($1,000.00)
Minimum Non-Refundable Deposit  ($500.00)


How did you hear about Bethesda?

Additional Comments:






Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



First Name:   Last Name:

I prefer to be called by:

Mailing Address:
City / State / Zip:

Preferred Phone:     Cell   Home   Work
Do you give Bethesda Workshops permission to leave a message?
    Yes   No

Alternative Phone:     Cell   Home   Work
Preferred E-mail address:

Birthdate:       Gender: Male   Female



Screening Questions

Your answers to any of the following questions do not automatically disqualify you from attending a workshop. If you mark "yes" to any question(s), Bethesda will contact you to be sure our workshop is the best fit, and your registration isn't final until after that's determined. If you have any "yes" answers, please wait to make travel arrangements.

Will this be your first experience being part of a therapeutic group?
    Yes   No

Do you anticipate having difficulty sharing as part of a small group?
    Yes   No


Please let us know if you've been diagnosed with any of the following:

Dissociative identity disorder (multiple personality)?
    Yes   No

Psychotic episode (seeing or hearing things that aren't real)?
    Yes   No

Bipolar disorder (manic depression)?
    Yes   No

Currently on or have been on medication for bipolar disorder?
    Yes   No

Is this medication effective?
    Yes   No

Borderline personality disorder?
    Yes   No

Experienced sucidal thoughts?
    Yes   No

Attempted suicide?
    Yes   No

If so, when?

Been hospitalized for mental or emotional health?
    Yes   No

If so, when?


Are you currently in counseling?
    Yes   No

Do you give Bethesda permission to contact your counselor?
    Yes   No

Have you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No

Counselor's Name       Counselor's Phone



Payment Options

$500.00 is minimal required deposit, which is non-refundable.
Full Payment  ($2,000.00)
Due Before Workshop  ($1,000.00)
Minimum Non-Refundable Deposit  ($500.00)


How did you hear about Bethesda?

Additional Comments:






Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



Participant #1's First Name:   Last Name:
Participant #2's First Name:   Last Name:




Required Pre-Requisite

Has each spouse attended his and her own individual Bethesda Healing workshop?
    Yes   No

Spouse 1 Workshop: Date Attended: (mm/dd/yyyy)
Spouse 2 Workshop: Date Attended: (mm/dd/yyyy)


Have either of you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No




Payment Options

$1,000.00 is minimal required deposit, which is non-refundable.
Full Payment  ($3,150.00)
Full Payment (Grand Slam discount)  ($2,750.00)
Minimum Non-Refundable Deposit  ($1,000.00)

Additional Comments:






Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



First Name:   Last Name:

Organization:
Position/Title:

Payment Options

Workshop Fee  ($69.00)
Workshop Fee & One Additional Hour of Supervision  (+$20.00)
Workshop Fee & Two Additional Hours of Supervision  (+$40.00)

Additional Comments:




Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.


Your First Name:
Your Last Name:
Your Spouse's First Name:
Your Spouse's Last Name:
Address:
City / State / Zip:
Your Cell:
Do you give Bethesda Workshops permission to leave a message?
    Yes   No

Your E-mail:
Your Spouse's Cell:
Your Spouse's E-mail:



Required Pre-Requisite

*Please answer the following questions to help us be sure this workshop is right for you.

When did you attend your Bethesda Workshops Healing for Couples workshop?


Are you both at least 90 days sober from love, sex, or co-addiction ?
    Yes   No

Are you both at least 90 days sober from chemical addictions?
    Yes   No

Do you both have a relationship with a trained therapist?
    Yes   No

Are you free from significant clinical diagnosis
(severe depression, PTSD, anxiety disorder, bipolar disorder, etc.)
    Yes   No

If not, are you under treatment and stable?
    Yes   No

Have you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No



Payment Options

$1,000.00 is minimal required deposit, which is non-refundable.
Workshop fee - $2,500.00 per couple (includes lodging & meals for both)
Minimum Non-Refundable Deposit  ($1,000.00)

Additional Comments:






Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



First Name:   Last Name:

Organization:
Position/Title:

Payment Options

Workshop Fee  ($69.00)
Workshop Fee & One Additional Hour of Supervision  (+$20.00)
Workshop Fee & Two Additional Hours of Supervision  (+$40.00)

Additional Comments:




Please be aware that all registrations are pending review and space availability at the workshop. Please do not pay for travel arrangements until you have received confirmation from a Bethesda staff member. If the workshop is full when you submit your registration, your non-refundable deposit will be applied to the next workshop. A deposit may not be transferred to another person.

 



First Name:   Last Name:

I prefer to be called by:

Mailing Address:
City / State / Zip:

Preferred Phone:     Cell   Home   Work
Do you give Bethesda Workshops permission to leave a message?
    Yes   No

Alternative Phone:     Cell   Home   Work
E-mail address:


Screening Questions

Please answer the following questions to help us be sure this workshop is right for you.

Have you attended an individual Bethesda Workshops healing workshop?          
    Yes   No
If yes, indicate which one and when
    Healing for Men   Healing for Women Healing for Partners Year attended


Are you at least 30 days sober from love or sex addiction ?
    Yes   No

Are you at least 30 days sober from chemical addictions?
    Yes   No

Are you currently, consistently meeting with a trained therapist?
    Yes   No

Are you consistently involved in a 12 step or similar support group?
    Yes   No

How often do you attend?
    Daily   2-5 times a week 1 time a week every other week

Are you free from significant clinical diagnosis (severe depression, PTSD, anxiety disorder, bipolar disorder, etc.) ?
    Yes   No

If so, are you under treatment and stable?
    Yes   No

Have you been accused or arrested for a contact offense (sexual abuse) of a minor or
fear that you could be accused or arrested because of behavior you've committed?
    Yes   No


Payment Options

$500.00 is minimal required deposit, which is non-refundable.
Total Amount of the Healing for Wounds Workshop ($2,000.00)
Minimum Non-Refundable Deposit  ($500.00)

Additional Comments: