Couples Workshop

Healing for Couples 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.

Prerequisite: Prior therapy is required to attend this workshop. If you have not attended a workshop at Bethesda previously, a team member will contact you for further information.

There is no arriving late, ending early or missing any part of the workshop during it’s schedule hours.
Take a look at the calendar and see if there's a date that works for you.

Once you reserve a date, you'll pay a deposit located at the bottom of this form.*

*Note: If your deposit isn't paid, you will not have a seat reserved for this workshop.
What date would you like to attend?*
How much would you like to pay today?
How much would you like to pay today calculation
Wife Information
Name*

First NameLast Name
I prefer to be called by
Address*

Mailing Address

Street Address Line 2

CityState

Zip
Preferred Email address*
example@example.com
Preferred Phone*
Please enter a valid phone number.
Do you give Bethesda Workshops permission to leave a message?*

YesNo
Birthdate*

MonthDayYear
Date
Prior Healing Workshops (Prerequisite)*
Date Attended
Group Leader
Husband Information
Name*

First NameLast Name
I prefer to be called by
Address*

Mailing Address

Street Address Line 2

CityState

Zip
Preferred Email address*
example@example.com
Preferred Phone*
Please enter a valid phone number.
Do you give Bethesda Workshops permission to leave a message?*

YesNo
Birthdate*

MonthDayYear
Date
Prior Healing Workshops (Prerequisite)*
Date Attended
Group Leader
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 youve experienced any of the following
Have you been accused or arrested for a contact offense (sexual abuse) of a minor or for possession of child pornography?*

WifeHusbandNeither
If so please explain:*
Are involved in the legal system because of your sexual behavior?*

YesNoType option 3
If so please explain:*
By signing below, I agree to the following:
Time Out of Daily Life

I understand thay by signing below, 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

I understand that all lodging is double occupancy and I will have a roommate for the duration of the workshop.
Email Communication

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.
Non-Refundable Deposit

The deposit is the minimum amount that can be paid and is required to secure a spot in the workshop. By signing below, 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).

Workshop Deposit

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Husband Signature*

Clear
This form was completed by:*
Wife Signature*

Clear
Additional Comments
Should be Empty:

Healing for Couples Workshop Registration

Wife Information

Husband Information

Screening Questions

By signing below, I agree to the following:

Time Out of Daily Life

Roommate

Email Communication

Non-Refundable Deposit