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 Women workshop is for women who personally struggle with pornography or some other form of sex or love addiction.

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

Preferred E-mail address:

Birthdate:

Are you currently in counseling?: Yes No

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 experienced any of the following:

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:

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

Have you experienced more than a passing thought of suicide in the last 60 days?: Yes No

If yes, please provide details:

Timeout from Daily Life

By typing my initials, I agree not to engage in any work responsibilities during the duration of the workshop. I also understand I will not be allowed to have contact with the outside world, and I agree to turn in my cell phone, laptop, tablet and any other devices that can access the Internet for the duration of the workshop. I understand that I won't have access to my phone or the Internet at the hotel and am not allowed to receive phone calls there. If I can’t 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 typing my initials, I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.:

Email Communication.

By typing my initials, I understand that 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. I acknowledge that email communication is not HIPAA compliant but I am giving Bethesda Workshops permission to communicate via email with me at the email address that I provided about my registration and details about my workshop. I release Bethesda Workshops from any liability that might result in the use of email communication.

Email address:

Initials:

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:

REGISTRATION IS NOT COMPLETE WITHOUT PAYMENT