Teen's Workshop

Healing for Teens 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 gender-specific workshop is for teens ages 15-18-year-olds who are still in high school or have just graduated. It’s a FAMILY program, not one just for the teens themselves. Whoever is identified as the teen’s parents (whether parents or step-parents – those who have primary residential and legal responsibility for the teen) is REQUIRED to attend.

The program is a GROUP process where multiple families attend at the same time (normally four to six families). The participants move back and forth between brief educational segments, activities, and group settings. Some of the groups will be separate gatherings of the teens and the parents. Other groups will be family therapy (teens and parents together) in a multi-family group setting.

There is no arriving late, ending early, or missing any part of the workshop during its scheduled hours.
Take a look at the selections below to 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?*
What date would you like to attend?*

August 6 @ 1:00 pm - August 9 @ 3:20 pm CDTSeptember 10 @ 1:00 pm - September 13 @ 3:20 pm CDTNovember 5 @ 1:00 pm - November 8 @ 3:20 pm CSTDecember 10 @ 1:00 pm - December 13 @ 3:20 pm CST
How much would you like to pay today?
Full Deposit Amount
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
Mom 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
Relation to Teen*

Biological MomAdoptive MomStep Mom
Dad 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
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 legal custody?*
If not, please indicate which parent has full legal custody.
Teen primarily lives with:*
Note: A divorced parent MUST provide the parenting plan that is part of the legal marital dissolution. If there is shared custody, the other parent 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 workshop paperwork. The Workshop Coordinator will provide the consent form for the other parent, when applicable.
Are there step parents involved in the teen's life?*
if yes, will they also be attending the workshop?
We highly recommend that a divorced or step parent who is active in the teen’s life also attends the workshop, provided the adults can cooperate and work together civilly toward the best interest of the teen. The teen must sign an Authorization to Release Information to a step-parent who is attending. If the presence of divorced or step-parents will be disruptive to the teen or the workshop environment, it’s best for only one parent to attend (with the documentation described above).
Additional Family Information
If additional step parents are attending the workshop beyond any listed as Teen's Mom or Dad above, please provide their information below:
Step Mom 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
Relation to Teen

Biological MomAdoptive MomStep Mom
Step Dad 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
Relation to Teen

Biological DadAdoptive DadStep Dad
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 indicate if anyone attending the workshop been diagnosed with or experienced any of the following:
In the last 60 days, have you experienced more than a passing thought of suicide?*

TeenMomDadStep MomStep DadNA
If yes, please explain*
Been accused or arrested for a contact offense (sexual abuse) of a minor or for possession of child pornography?*

TeenMomDadStep MomStep DadNA
If yes, please explain*
Are involved in the legal system because of your sexual behavior?*

TeenMomDadStep MomStep DadNA
If yes, please explain*
Is the teen currently in counseling*

YesNo
Are the parents currently in counseling?*

YesNo
By signing below, the family agrees 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

This registration form has been completed by:*
Family Representative Signature*

Clear
Additional Comments
Should be Empty:

Healing for Teens Workshop Registration

Teen Information

Mom Information

Dad Information

Family Information

Additional Family Information

Step Mom Information

Step Dad Information

Screening Questions

By signing below, the family agrees to the following:

Time Out of Daily Life

Roommate

Email Communication

Non-Refundable Deposit