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The Underground Workshop Men's Registration Form
General Information
Workshop Dates
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March 13-16, 2024
August 14-17, 2024
November 13-16, 2024
Name
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Date
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Address
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City
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State
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Zipcode
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Home Phone
Cell Phone
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Age
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Email Address
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Date Of Birth
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Church or Institution's Website:
Name Of Church or Institution:
Relational Information
Marital Status
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Single
Engaged
Married
Separated
Divorced
Widowed
If Married, Engaged, Divorced or Widowed, How Long Have You Been So:
Family Of Origin
Please Identify Any Of The Following You Experienced
Physical Abuse
Emotional Abuse
Sexual Abuse
Drug/Alcohol Addiction
Religious Upbringing
Are You Currently In Counseling
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Yes
No
If so, what is your counselor's email:
Present Issues & Goals
Please Check Any Of The Following Symptoms Or Problems That You Have Experienced Pertaining To Sexual Addiction:
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Sexually Abused
Verbally Abused
Emotionally Abused
Physically Abused
Prostitution
Phone Sex
Homosexuality
Addictive Masturbation
Adultery
Indecent Liberties
Addiction To Pornography
Voyeurism
Rape
Exhibitionism
Molestation
Please Describe Why You Are Coming To The Underground Workshop, Issues, Problems, Symptoms, How Long, Etc?
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Sexual Addiction Checklist
Age Of First Masturbation:
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Age Of Exposure To Porn:
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How Would You Like To Pay:
Downpayment ($475.00) with 2 monthly payments of $200.00 each
Workshop Payment In Full ($875.00)