Application: Beginning Experience Weekend

Choose the weekend best for you and type it in the first box below.


Buckeystown, MD ~ March 26-28, 2004

 Choose a weekend

Which weekend are you applying for:
Please put Date/location  

Your email address:

  Full Name:  
 Home Address:  
 City:  
 State (Abrev):   Zip:
 
   
 Home phone:  
 Work phone:  
   
How long separated? yrs months 
How long divorced? yrs months 
 How long widowed?  yrs months 
 No. of yrs married  
 Children:  
 Number of children:  
 Ages of children:  

 

Are you presently in counseling or therapy?

Do you give us permission to contact your counselor or therapist?

Do you have any experience working in therapy, sharing or discussion groups?

Please Explain:

  Therapist's Name:  
   Therapist's Address:  
 City:  
 State (Abrev):   Zip:
 Emergency phone:  
 Work phone:  

How did you learn about B.E.?

List anyone you know who plans to come on the same weekend.

Call 202-298-9717 and leave a message with your name and phone number and
let us know that you have sent a completed form via email.