Registration

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Healing for Partners >

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Healing for Couples Advanced >

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
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 ($1,500.00)
Due Before Workshop ($700.00)
Minimum Non-Refundable Deposit ($500.00)

How did you hear about Bethesda?

Additional Comments:

Non-refundable Deposit. By checking this box, I understand that $500 of what I have paid is a non-refundable deposit. If I cannot attend the workshop, I understand that my non-refundable deposit cannot be counted as a donation and I will not receive a tax credit.
Email Communication. By checking this box, I understand Bethesda Workshops will communicate with me via the email address I have provided. I authorize such email communications and I am aware of the risks regarding the lack of confidentiality associated with email.
Timeout from Daily Life. By checking this box I agree not to engage in any employment responsibilities during the duration of the workshop. I also understand I will not be allowed to have contact with the outside world during the workshop, and I agree to turn in my cell phone, tablet, and any other technology devices that can access the Internet for the duration of the workshop. If I am unable to maintain these boundaries and take a timeout from daily life, I will postpone my attendance at a Healing Workshop until I’m able to do so.
Roommate. By checking this box I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.

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.

Screening Questions

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

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.

Screening Questions

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

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

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.
Full Payment ($2,500.00)
Full Payment (Grand Slam discount) ($2,250.00)
Minimum Non-Refundable Deposit ($1,000.00)

Additional Comments:

Non-refundable Deposit. By checking this box, I understand that $1,000 of what I have paid is a non-refundable deposit. If I cannot attend the workshop, I understand that my non-refundable deposit cannot be counted as a donation and I will not receive a tax credit.
Email Communication. By checking this box, I understand Bethesda Workshops will communicate with me via the email address I have provided. I authorize such email communications and I am aware of the risks regarding the lack of confidentiality associated with email.
Timeout from Daily Life. By checking this box I agree not to engage in any employment responsibilities during the duration of the workshop. I also understand I will not be allowed to have contact with the outside world during the workshop, and I agree to turn in my cell phone, tablet, and any other technology devices that can access the Internet for the duration of the workshop. If I am unable to maintain these boundaries and take a timeout from daily life, I will postpone my attendance at a Healing Workshop until I’m able to do so.
Roommate. By checking this box I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.

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:
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:

Non-refundable Deposit. By checking this box, I understand that $1,000 of what I have paid is a non-refundable deposit. If I cannot attend the workshop, I understand that my non-refundable deposit cannot be counted as a donation and I will not receive a tax credit.
Email Communication. By checking this box, I understand Bethesda Workshops will communicate with me via the email address I have provided. I authorize such email communications and I am aware of the risks regarding the lack of confidentiality associated with email.
Timeout from Daily Life. By checking this box I agree not to engage in any employment responsibilities during the duration of the workshop. I also understand I will not be allowed to have contact with the outside world during the workshop, and I agree to turn in my cell phone, tablet, and any other technology devices that can access the Internet for the duration of the workshop. If I am unable to maintain these boundaries and take a timeout from daily life, I will postpone my attendance at a Healing Workshop until I’m able to do so.
Roommate. By checking this box I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.

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
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:

Non-refundable Deposit. By checking this box, I understand that $500 of what I have paid is a non-refundable deposit. If I cannot attend the workshop, I understand that my non-refundable deposit cannot be counted as a donation and I will not receive a tax credit.
Email Communication. By checking this box, I understand Bethesda Workshops will communicate with me via the email address I have provided. I authorize such email communications and I am aware of the risks regarding the lack of confidentiality associated with email.
Timeout from Daily Life. By checking this box I agree not to engage in any employment responsibilities during the duration of the workshop. I also understand I will not be allowed to have contact with the outside world during the workshop, and I agree to turn in my cell phone, tablet, and any other technology devices that can access the Internet for the duration of the workshop. If I am unable to maintain these boundaries and take a timeout from daily life, I will postpone my attendance at a Healing Workshop until I’m able to do so.
Roommate. By checking this box I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.