3 Steps to Register:

Download Welcome Letter + Medical Release
Complete the following form
Upload the Medical Release via the Form below or email [email protected]

Download Documents to Sign

Complete + Submit the Registration Form Below

Step 1 of 4

Participants Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

T-shirt Size(Required)

Emergency Contact(Required)

First Last

Relationship(Required)

Phone(Required)

Consent (Please Read Thoroughly)(Required)

By signing below, I acknowledge that I have read, understand, and agree to the following terms and conditions that will be in effect before, during, and after my involvement with Tonya L. Bassett Counseling’s, Healing Within Program and its program guidelines.
I agree to accept the concept of a chemical-free existence during the program. This means abstinence from all mind and mood affecting drugs and chemicals, including alcohol, nicotine, and marijuana during this period of time. I understand that any use of these chemicals will result in my discharge from the program. Since this is a nicotine-free program, participants who smoke or use tobacco in other forms will address their nicotine use as a part of this program. I understand I will be required to abstain upon my arrival to the program and throughout my stay at the site.

I understand this is a prepaid program, and I agree to meet all financial requirements prior to my entering the program. In addition to Healing Within’s pre-program registration and cancellation fee policies, I understand the program is on a "fee for service" basis. This means that since Tonya L. Bassett Counseling, Inc., Breathe – A Center for Healing & Wellness, LLC and the Healing Within Program has made prior arrangements and incurred costs to provide said services for me, I will not be entitled to or receive a refund of any fees I have paid for any reason if I do not cancel 45 days ahead of the scheduled program start date, even if I do not participate in or receive all of the services scheduled for me. Whether I complete the program as scheduled, or I am discharged from, or I discharge myself from the program before its completion, I understand I will not be entitled to or receive a refund of any portion of the prepaid program costs, including transportation to or from the program site.

I understand that seeking and receiving insurance reimbursement is solely my responsibility and not the responsibility of Tonya L. Bassett Counseling, Inc., the Healing Within Program and/or Breathe – A Center for Healing & Wellness, LLC.
The Healing Within Program does not provide DSM-IV psychological diagnosis or CPT codes to insurance companies.
I understand and accept that the Healing Within Program makes no explicit or implied guarantees or warranties as to my successful completion of the program, the quality of my experience during the program, or my post-program experiences directly or indirectly resulting from my participation in the program.

I understand my participation in this program is voluntary, and the program may be physically and emotionally intense. I agree to accept such risks and I assume responsibility for such stress/distress and/or other effects of my participation. I hereby release, discharge and hold harmless Tonya L. Bassett Counseling, Inc., the Healing Within Program, and Breathe – A Center for Healing & Wellness LLC, and all of its staff of and from any and all claims, causes of action, demands, or judgments arising out of or in any way connected with my participation in the Healing Within Program and all related activities, including those arising out of the negligence of any of the aforementioned parties. I understand that participation in any of these activities contains certain risks of physical injury or death. I agree to assume fully the risk of injury or death arising from any such activity.

I understand as part of Healing Within’s mission to educate professionals about trauma and associated marital and family issues, Healing Within allows approved clinical and/or pastoral professionals to observe the program.

I understand I have the responsibility of assuming a leadership role regarding my own care and safety in this workshop.
As a condition of acceptance in the program, I agree to provide my complete medical history as provided for by the form entitled Healing Within Program Medical History and incorporated herein as if fully set forth in this contract.

I understand and agree that it may be necessary to make my medical history available to a hospital, physician or other health care provider in the event that I am in need of medical treatment; therefore, I authorize Tonya L. Bassett Counseling, Inc., and the Healing Within Program staff to release my medical history for that purpose. In the event of any medical emergency, I hereby authorize and give my full consent to Tonya L. Bassett Counseling, Inc., and the Healing Within Program staff to take all appropriate measures to provide me with medical assistance including, if appropriate, permission to transfer me to another facility. I also authorize Tonya L. Bassett Counseling, Inc., and the Healing Within Program staff to contact any of my current or former health care providers and family members should the Healing Within Program staff believe it is in my best interest to do so.

I understand that my participation in the program may involve interaction with other program participants who may have a contagious/infectious disease which may include but are not limited to known and unknown flu viruses, COVID-19, Hepatitis, HIV, bacterial infections, etc. and that the Healing Within staff takes universal precautions for the safety of all participants. I agree to assume the risk of such exposure and I agree to hold Tonya L. Bassett Counseling, Inc., the Healing Within Program and its staff, Breathe – A Center for Healing & Wellness LLC, harmless and free from any and all claims, including reasonable attorney fees.
I have fully and truthfully disclosed all information regarding my medical and physical history, including any medical conditions and medications which I am currently taking, whether prescribed or not.

I have fully and truthfully completed all documents which the program staff has provided to me.
The program will take place in a retreat setting. As such, I understand that the program participants, including myself, are not in a licensed health care setting or facility and will not receive medical supervision or monitoring. The program experience is designed to promote wellness and improve the ability of participants to function in a healthier manner emotionally, spiritually and psychologically. The program experience is not a substitute for inpatient, or extended outpatient treatment. I will not reveal or discuss outside of any group process anything that happens or is said or done within any group process. I will not reveal the identities of any participants, family members or program participants who are or may have been at Healing Within. I understand that violation of this confidentially pledge will be grounds for immediate dismissal from any/all Healing Within programs, and may subject me to civil and/or criminal penalties.

I understand that Tonya L. Bassett Counseling, Inc., and the Healing Within Program operates under strict privacy policies, but group members will keep strict confidentiality.

I understand that the Healing Within Program cannot completely control the nature of information participants may reveal about themselves in the group process.

I have reviewed this agreement and the Healing Within Program welcome letter and guidelines carefully. I have been informed, to my satisfaction, as to what may occur during the Healing Within Program.

This contract contains the entire agreement between the parties hereto, and its terms are contractual and not a mere recital. I further state that I have carefully read the foregoing terms & conditions, know the contents thereof, and I sign the same as my own free act.
I hereby agree to accept and abide by the policies, guidelines, conditions, and procedures as set forth in this agreement and the Healing Within Program welcome letter and guidelines.

I agree to the Program Contract Agreement

Signature(Required)

CHEMICALS DURING PROGRAM AND MEDICAL NEEDS(Required)

Mood altering chemicals, including alcohol, are not allowed. You cannot arrive at the program with the appearance of alcohol/intoxication or any mood altering substances; if we perceive that you are intoxicated you will forfeit your program fees, you will be asked to leave and you would forfeit your right to participate in the program. If you have severe allergies of any kind, please come with the necessary medication in the unlikely event of any reaction(s). If you bring non-prescription medications to the program that we feel will interfere with your work or your ability to get the most out of this experience, you may be asked to allow us to hold this medication for the duration of the program. If you have any questions prior to the program regarding any prescription or non-prescription drugs you need to take, please check with the program’s director.

CONFIDENTIALITY(Required)

Confidentiality regulations protect your right to anonymity as a participant in this program. We expect that you will protect that right for fellow participants. What you choose to say to others about yourself and/or your experience is up to you. Be aware that because the program is a group process, we cannot guarantee that group participants will keep confidentiality. All licensed counselors and helping professionals who function as our group leaders are required to report certain information where there is a clear and immediate danger to you or someone you could endanger, or indication of abuse to a minor and/or confirmed or suspected domestic violence/abuse. (See the page titled CONTRACT AGREEMENT for more information.) Please ask permission of participants before you use your camera. Do not post photos on social networking sites without written permission from all participants in photos. Cameras are not allowed during group process or presentations. Audio and video recording is prohibited at any time.

ROOMING(Required)

In order to provide safety, privacy, and a sanctuary, assigned sleeping rooms will be off limits to all other participants at all times. It is important that you understand that the Healing Within Program cannot anticipate, monitor, or control participants unique sleeping/living habits or their sensitivities to others habits. If you have any unique sensitivities such as allergies to hair spray, perfume, etc., snoring or other night sounds, light, etc., it is your responsibility to take care of those sensitivities by bringing to the program items needed to provide for your comfort and safety. Such items might include allergy masks, sleeping masks, ear plugs, headphones, white noise machines, etc. The Healing Within Program may not be in a position to offer any relief from such sensitivities by making roommate/room changes, etc. If you have any such unique sensitivities or sleeping conditions such as the use of a breathing machine, insomnia, excessive snoring, etc. let us know so we can determine our ability to accommodate your special needs. We may have a limited number of rooms available. Towels and wash cloths will be provided once during the week and bed linens will be provided for the week. Please respect your roommates by keeping your living area neat and your bed made. Outdoor fires will only be allowed when initiated by the Healing Within staff.

GENERAL GUIDELINES(Required)

We require that when you walk or jog, please inform staff of your intentions. On the other hand, isolation can enhance your experience here also. If you become aware of a relationship between clients that has developed, or if you currently have a relationship with other clients at this program, report that information to Healing Within staff as soon as you become aware of it. Respect property. Any willful damage of property will be the financial responsibility of the participant. Do not self-medicate, share medications (prescription or non-prescription), or provide health assistance to other participants, unless directed to do so by staff.

PHONE AND EMERGENCIES(Required)

After the first morning of the program, you will be asked to minimize cell phone usage. There is limited cell phone service available. To help you focus on the work at hand no TV’s, newspapers, or radios will be available. The phones at the program site are for emergency use only. Please be advised that Healing Within cannot provide direct medical assistance. If you need to see a doctor, arrangements can be made. Cost of transportation to and from medical assistance is not included in regular program fees. Incoming emergency messages will be forwarded to you as soon as possible. Non-emergency incoming phone calls will be forwarded to you in a timely fashion. Except for emergencies, you will not be permitted to use the program site phone once the program has begun in order to help you focus on your work.

CONTAGIOUS/INFECTIOUS CONDITIONS(Required)

We believe it is both safe and appropriate that individuals with certain medical and physical conditions be permitted to participate in our programs. Such contagious/infectious conditions may include, but are not limited to: known and unknown cold and flu viruses, hepatitis, HIV, bacterial infections, etc. All participants and staff should exercise reasonable caution in their interactions with each other to minimize their exposure and the exposure of others to infectious diseases. We strongly suggest that individuals avoid sharing personal grooming items, such as razors, toothbrushes, etc., and that each person assumes responsibility for throwing away their own tissues and other similar items they may use.

GENERAL DRESS CODE(Required)

Appropriate dress for the Healing Within Program includes comfortable, casual wear. Wear shoes outside at all times. T-shirts, sweatpants/yoga pants/sweatshirts and jeans are all appropriate. For group, we suggest you be very comfortable. Appropriate length shorts are permitted. Inappropriate clothing include items such as: short shorts, mini skirts, halter tops, low cut tank tops, open shirts, or excessive jewelry. For health reasons, you will need to wear foot coverings in the meeting and dining rooms.

EXERCISE AND DESIGNATED AREAS(Required)

Because it is important in a program that we establish a community setting, it is REQUIRED that participants stay on the premises at ALL TIMES. Participants are not permitted to go beyond the fencing or front entrance of the program site for any reason at any time during the program unless with program staff. Property boundaries are marked by fences. In case of an emergency, contact a staff member. Physical activities are optional, so please be gentle with yourselves. If you are experiencing any discomfort or ailment, please notify the staff as soon as possible. For walking, we suggest that you inform staff of your whereabouts. Also, be aware that there are snakes, ticks, fleas and other wildlife/insects in Illinois.

DINING AND MEETING ROOMS(Required)

Participants may be asked to assist with certain tasks, such as helping prepare/clean-up for meals or set up for presentations to help facilitate the program. We will be providing snacks and refreshments for your breaks. Snacks are to be consumed only in the areas outlined during the first orientation session. All participants must be a part of every meal whether or not they choose to eat, and you must be on time for meals. Please no food or drinks other than water in bedrooms. Please use a coaster on furniture at all times. The philosophy of our menu is to provide meals and snacks that are nutritious and well balanced. We will do our best to accommodate special diets. If you have special dietary needs, consult with the program director before you sign up to see if our meal plan will work for you.

REMINDERS(Required)

We may take pictures throughout the week. There will be release forms to sign if you agree to have your picture used by the Healing Within Program. Please ask permission before taking pictures of participants. No photos, audio, or video recording will be allowed during presentations or small group. Complete the evaluation forms in your packet. We will collect them at the end of the week. Please report any damage to a staff member. Tonya L. Bassett Counseling, Inc., the Healing Within Program and its staff, and Breathe – A Center for Healing & Wellness LLC, are not responsible for lost or stolen property.

WE EXPECT THAT YOU WILL(Required)

Be honest about matters that relate to you, and be an active participant in your process, including education and group sessions. Be considerate and respectful of the rights of fellow participants, the Healing Within Program staff, other's property and the property and furnishings of Breathe – A Center of Healing & Wellness, LLC. -Help keep your room and community rooms clean. -Attend all scheduled meetings, sessions, meals and events, and be on time. All sessions will starton time; participants are expected to be on time. If you are late, you may not be allowed in. -Complete all reading, writing and other assignments. If you have concerns for your safety or wellbeing, tell a staff member.

SUMMARY(Required)

This program can be a safe place to feel, share, and be vulnerable. In order to preserve and enhance safety, we will not hesitate to discharge someone, if necessary, for the welfare of the whole group. Grounds for discharge will include: a.Possession, sale or use of drugs and/or alcohol. b.Violating program guidelines. c.Actual or threatened verbal and/or physical assault. d.Inappropriate behavior interfering with another's experience. e.Dishonesty.

Signature

3 Steps to Register:

Download Welcome Letter + Medical Release

Complete the following form

Upload the Medical Release via the Form below or email [email protected]

Complete + Submit the Registration Form Below

Questions? Send us a note

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