5-Day Men's Intensive Application

1
Email Address* This field is required.
name@example.com
2
Full Name* This field is required.
First Name
Last Name
3
Date of Birth (MM/DD/YYYY)* This field is required.
Month
Day
Year
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Can we leave a voicemail?* This field is required.
Yes
No
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Have you read Dr. Barta's book TINSA (Trauma-Induced Sexual Addiction) or his newest Reconnection book?* This field is required.
Yes
No
8
Relationship Status* This field is required.
Please Select
Please Select
Committed Relationship
Married
Divorced
Widowed
9
Readiness to change* This field is required.
Please Select
Please Select
0 is the lowest in your readiness to change
1
2
3
4
5
6
7 is the highest in your readiness to change
10
What’s going wrong in your life right now that made you apply for this intensive? (what it’s doing to you, your relationship, or your sense of self)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
What have you already tried to stop, fix, or control this—and why hasn’t it worked?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
If nothing changes, what are you afraid you’ll lose?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
How long have these behaviors been an issue?* This field is required.
Please Select
Please Select
1-5 years
5-10 years
10-20 years
20+ years
14
Have you recently been discovered or are you in crisis because of your behaviors?* This field is required.
Yes
No
15
Please rate your emotional stability* This field is required.
Please Select
Please Select
0 - Feel very emotionally unstable
1
2
3
4
5
6
7 - Feel very emotionally stable
16
Name of your current therapist* This field is required.
17
Is your therapist a Certified Sex Addiction Therapist?* This field is required.
Yes
No
18
How many alcoholic drinks do you have per day?* This field is required.
19
What recreational drugs do you use daily?* This field is required.
20
What are your current medications?* This field is required.
21
Is your need for treatment related to a sexual crime? If yes, please describe.* This field is required.
*Note, Dr. Barta is unable to treat sexual offenders.
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