Healing for Men Online Workshop Registration

When your registration and payment are submitted, you’ll receive a payment confirmation email. Within one business day, you’ll get a separate email from the Bethesda Workshops team with further information and instructions about the workshop paperwork.

The Healing for Men workshop is for men who personally struggle with pornography or some other form of sex or love addiction. You're registering for the ONLINE workshop.

There is no arriving late, ending early or missing any part of the workshop during it’s schedule hours.

Start Date of Workshop:

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:

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

Are you currently in counseling?: Yes No

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

Counselor’s Name:
Counselor’s Phone:

Screening Questions

Your answers to any of the following questions don’t automatically disqualify you from attending a workshop. If you mark "yes" to any question(s), Bethesda Workshops will contact you to be sure our workshop is the best fit. If we determine it isn’t, we’ll refund your deposit. If you have any "yes" answers, please wait to make travel arrangements until you speak with our Clinical Specialist.

Please let us know if you've been diagnosed with or experienced 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 suicidal thoughts?: Yes No

If so, date of last occurrence:

Attempted suicide?: Yes No

If so, when?:

Been hospitalized for mental or emotional health?: Yes No

Been accused or arrested for a contact offense (sexual abuse) of a minor or for possession of child pornography?: Yes No

If yes, please provide details:

Fear that you could be accused or arrested because of your sexual behavior (other than for soliciting prostitution)?: Yes No

Are involved in the legal system because of your sexual behavior?: Yes No

Email Communication.

Bethesda Workshops communicates with participants extensively by email, including all the workshop paperwork for you to complete and numerous updates and details about your workshop. Be sure the email you entered is one you check regularly. Please read and accept the following information about email communication by typing your initials in each indicated place.

Email can be forwarded, intercepted, printed and stored by others.:

Employers generally have the right to access any email sent or received by a person at work.:

Bethesda Workshops staff other than the email’s directed recipient may read and process email.:

Engaging in email communication with Bethesda Workshops staff, including clinical staff, does not create a client relationship, and such communication cannot be considered privileged between a therapist and client.:

Bethesda Workshops will not be liable for any perceived therapeutic advice contained in electronic communication.:

Bethesda Workshops will not be liable for lost, intercepted or misdirected electronic communication.:

Email communication is a convenience and not appropriate for emergencies or time-sensitive issues.:

By typing my initials, I confirm I have read and understand these potential risks and authorize Bethesda Workshops to communicate with me via the email address I have provided on this registration. (I understand I may inform Bethesda Workshops of my preference for a different email address at any time.):

Email address:

Date:

Requirements for ONLINE Workshop

Stable internet connection
Desktop or laptop with video capability (participating by phone not allowed; using iPad or tablet discouraged)
Ability to use technology to participate in online format
Private space with closed door
Ability to participate from 9 am-5 pm Central time without distraction as detailed in section about Bethesda Bubble

“Bethesda Bubble”

Not responsible for childcare, work, or any other activities during workshop hours, including at lunch
No phone or other devices in workshop space
No phone calls, texts, TV, online activity, work, or responsibilities during breaks and lunch
Arrangement with spouse/partner to maintain boundaries that ensure your focus during workshop. Bethesda Workshops will communicate with that person to explain these boundaries.
No alcohol or drugs not properly prescribed for you during entirety of workshop, including overnight
None or very limited work or other responsibilities during evenings. May have overnight assignments.

Parameters About Participation

If you miss a session, you will be terminated from the workshop without refund and still be responsible for paying your balance
If you don’t complete an assignment, you will be terminated from the workshop without refund and still be responsible for paying your balance
If you are interrupted during a session, you will be terminated from the workshop without refund and still be responsible for paying your balance

By typing my initials, I confirm I have read and understand these requirements, the boundaries about the “Bethesda Bubble,” and the parameters regarding my participation:

Payment Options

Non-refundable Deposit. The deposit is the minimum amount that can be paid and is required to secure a spot in the workshop. By typing my initials, I understand that the deposit is non-refundable and cannot be counted as a donation for tax purposes. If I cannot attend the workshop, I understand that my deposit may be transferred to one of the next two scheduled workshops (a change fee may apply). If Bethesda Workshops determines that I am not an appropriate candidate for the workshop setting, my deposit will be refunded.:

Additional Comments:

Participant Signature: