Registration » Bethesda Workshops

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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

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:

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.

Presently, the Jan. 25-28, 2012 workshop is full. Please call the office to be put on a waiting list - 866-464-4625. If you register online, you will automatically be placed in the March 21-24, 2012 workshop and be put on the waiting list for the January workshop. Please contact us with any questions.

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

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

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

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:

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: