Teens Online Group

Healing for Teens Online Group Registration
When your registration and deposit are submitted, your spot will be secured. Within one business day, you’ll get a separate email from the Bethesda Workshops team with further information and instructions about the participant paperwork.

This gender-specific online group is for teens ages 16-19 year-olds. This online group is a family program and there will be a few meetings with parents. At least one parent of the participating teen is REQUIRED to attend the parenting group sessions.
Teen Information
Full Name*

First NameLast Name
I prefer to be called by
Gender*
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
Mother's Information
Full 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
Relation to Teen*

Biological MomAdoptive MomStep Mom
Father's Information
Full 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
Relation to Teen*

Biological DadAdoptive DadStep Dad
Family Information
Are the parents listed above married to each other?*
Do both the mother and the father have shared legal custody?*
If not, please indicate which parent has full legal custody.
Teen primarily lives with:*
Note:If there is shared custody, both parents MUST SIGN a consent form for the teen's treatment. You may still register to hold your spot, but this documentation must be submitted before you are considered fully registered and can receive the group paperwork. The Workshop Coordinator will provide the consent form for the other parent, when applicable.

My Products

Pay in FullOne single payment of $650. No other payments will occur.

$650.00 one-time payment

$325 Today, $325 Next Month Product Image

$325 Today, $325 Next MonthOne deposit payment of $325, another $325 charged 1 month from now.

$325.00 for each month

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

By signing below, the family agrees to the following:
Email Communication

I understand that Bethesda Workshops communicates with participants extensively by email, including all the online group paperwork for you to complete and numerous updates and details about your group. 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. I release Bethesda Workshops from any liability that might result in the use of email communication.

All parents will be included in all communication about registration, online group details etc.
Non-Refundable Deposit

The deposit of $325 is the minimum amount that can be paid and is required to secure a spot in the group. By signing below, I understand that the deposit is NON-REFUNDABLE and cannot be counted as a donation for tax purposes.
This registration form has been completed by:*
Family Representative Signature*

Clear
Additional Comments
Should be Empty:

Healing for Teens Online Group Registration

Teen Information

Mother's Information

Father's Information

Family Information

By signing below, the family agrees to the following:

Email Communication

Non-Refundable Deposit