RECOVERY INTENSIVE REGISTRATION

SEX & PORN ADDICTION INTENSIVE

The Red Ink Recovery Intensives is for men who personally struggle with pornography or some other form of sex or love addiction.

For more details click here.

Join us as we:

REDEFINE STORY, REDEEM LIFE, REDREAM TOMORROW &

REDISCOVER YOU!

When your registration and payment are submitted, you will receive a payment confirmation email. Within one business day, you will receive a separate email from the Red Ink Recovery Intensives team with further information and instructions about the workshop paperwork.

INTENSIVE DATES

March 31 - April 2, 2022

November 3 - 5, 2022

Contact Information

Cell

Home

Work

Do you give Red Ink Recovery permission to leave a message?

Yes

Cell

Home

Work

Additional Information

Will this be your first experience being part of a therapeutic group?:

Yes

Do you anticipate having difficulty sharing as part of a small group?:

Yes

Are you currently in counseling?:

Yes

Do you give Red Ink Recovery permission to contact your counselor?:

Yes

Counselor's Name:

Counselor's Phone:

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), Red Ink Recovery 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 let us know if you've been diagnosed with or experienced any of the following:

Dissociative identity disorder (multiple personality)?

Yes

Psychotic episode (seeing or hearing things that aren't real)?

Yes

Bipolar disorder (manic depression)?

Yes

Currently on or have been on medication for bipolar disorder?

Yes

Is this medication effective?

Yes

Borderline personality disorder?

Yes

Experienced strong suicidal thoughts?

Yes

Attempted suicide?

Yes

If so, when?

Been hospitalized for mental or emotional health?

Yes

Been accused or arrested for a contact offense (sexual abuse) of a minor or for possession of child pornography?

Yes

If yes, please provide details:

Fear that you could be accused or arrested because of your sexual behavior (other than for soliciting prostitution)?

Yes

Are involved in the legal system because of your sexual behavior?

Yes

Timeout from Daily Life

By typing my initials, I agree to limit engagement with any outside work responsibilities, with a Red Ink Recovery preferred goal of complete outside work abstinence, for the duration of the workshop. I also understand and agree to limit engagement with family, friends, or anyone in the outside world, with a Red Ink Recovery preferred goal of complete communication abstinence. I agree to turn off my cell phone, laptop, tablet, and any other devices that can access the Internet for the duration of the workshop, with the only exception of use for the Red Ink Recovery Intensive itself. I understand and agree to abstain from use of all electronic devices, including TV at the hotel. If I feel I can’t maintain these boundaries and take a timeout from daily life, I will postpone my attendance at a Red Ink Recovery Intensive until I’m able to do so:

By typing my initials, I understand and agree that I am responsible for my own travel, lodging, and meals for the duration of the Red Ink Recovery Intensive, and that these expenses are NOT included in my Intensive payment.

Email Communication

Red Ink Recovery communicates with participants extensively by email, including all the Red Ink Recovery Intensive paperwork for you to complete and numerous updates and details about your Red Ink Recovery Intensive. Please read and accept the following information about email communication by typing your initials in each indicated place.

Email can be forwarded, intercepted, printed and stored by others:

Employers generally have the right to access any email sent or received by a person at work:

Red Ink Recovery staff other than the email’s directed recipient may read and process email:

Engaging in email communication with Red Ink Recovery staff, including clinical staff, does not create a client relationship, and such communication cannot be considered privileged between a therapist and client:

Red Ink Recovery will not be liable for any perceived therapeutic advice contained in electronic communication:

Red Ink Recovery will not be liable for lost, intercepted, or misdirected electronic communication:

Email communication is a convenience and not appropriate for emergencies or time-sensitive issues:

By typing my initials, I confirm I have read and understand these potential risks, and authorize Red Ink Recovery to communicate with me via the email address I have provided on this registration. I understand I may inform Red Ink Recovery of my preference for a different email address at any time.

Payment Options

$2000 is the required payment to attend a 3-day Red Ink Recovery Intensive.

Due to the budget commitments Red Ink Recovery will make on my behalf, payments for the Intensive are not refundable, unless Red Ink Recovery determines that in their professional opinion I am not an appropriate candidate for the workshop setting.

However, the Intensive payment may be transferred to one of the next two scheduled workshops, based on open spot availability.

By signing below, I understand and agree to the following:

I understand and agree that the Intensive payment is not refundable unless it is determined I am not an appropriate candidate for the workshop setting.

I understand and agree that my Intensive payment may be transferred to one of the next two scheduled workshops, depending on spot open availability.

I understand and agree that my Intensive payment cannot be counted as a donation for tax purposes.

Any additional comments:

Your Signature (draw using mouse or finger)