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Fill Out The Form Below To Apply For The 5-Day Men's Intensive

"*" indicates required fields

Select Service Desired*

Name*

Date of Birth*

Phone*

Email*

Can we leave a voicemail?*

Address*

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

Have you read Dr. Barta's book TINSA (Trauma-Induced Sexual Addiction)?*

Relationship Status*

Readiness to change*

Describe in detail your need for treatment (Ex. Type of addiction, how long, consequences from behaviors, current treatment for behaviors)*

How long have these behaviors been an issue*

Have you recently been discovered or are you in crisis because of your behaviors?*

Please rate your emotional stability*

Name of your current therapist*

Is your therapist a Certified Sex Addiction Therapist*

Describe how many alcoholic drinks do you have per day?*

What recreational drugs do you use daily?*

What are your current medications?*

Is your need for treatment related to a sexual crime? - Please Describe*

Phone

This field is for validation purposes and should be left unchanged.

*Note, Dr. Barta is unable to treat sexual offenders.