Austin Adolescent Experience Registration Form

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Thank you so much for your interest in the Liberation: Adolescent Experience workshop in Austin, September 30-October 5, 2025.

The first Liberation Adolescent Experience is for those that have already participated in the Childhood Experience. If you have not participated in Childhood Experience please do NOT fill this out. In 2026 we will not have any prerequisite for this workshop. However, for the firt time offering this workshop we are requesting that everyone have taken the Childhood Experience.

The first step of your transformational journey begins with this registration form. All information provided is completely confidential and will only be shared between the event organizer and faculty.

Please answer all questions so we can help you have the best experience possible. The organizer will reach out if there are any issues or if any of your selections are no longer available.

Thank you for taking the time and we look forward to connecting with you soon.

With love,

Julia Vieau

Liberationworkshops@gmail.com

Who referred you?

You can list a person or if you were referred from an online source, please list the source.

First / Last name

Email address

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Phone Number

City & State/Country

General Information

Age:

Facebook Link:

Gender Identity

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Female

Male

Nonbinary

Other:

Dietary Restrictions

Please note that diets beyond this list may not be able to be accommodated. Please bring supplemental foods if you have strict requirements. There will be meat served at most meals with veg options.

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Gluten Free

Lactose Free

Vegan

Vegetarian

Omnivore

Other: you can list any other dietary restrictions below

Dietary Restrictions

List any specific dietary restrictions below. Please note that we are not able to accommodate special diets. Reach out to the organizer if you have any questions or concerns regarding food.

Health Needs:

Do you have any health challenges or physical limitations that we should know about? Medications you need? Special needs?

Emergency Contact

Name and Relationship

Emergency Contact Phone Number

Mental Health History

Tell us about your life experiences. These answers are kept confidential. It is not recommended to attend this workshop if you have an active issue with substances and/or you have been actively suicidal in the past year. If you have a lot of life instability it is better to defer doing this workshop when you feel more stable in your life. Please be honest so we can support you in deciding if this workshop is the right fit for your at this time. It is also recommended that you have completed foundational therapy.

Do you have a current or prior mental health diagnosis?

Have you been in crisis in the past year (ie serious suicidal thoughts/ attempts or hospitalizations)?

How much altering substances do you consume on a regular basis? (This includes alcohol, Cannabis, psychedelics, other drugs. This does not include: sugar, coffee, or tobacco)

Prior history in adolescents you would consider traumatic? You do not need to go into details. Just state the situations.

What was your family constellations? What was your relationship like with your siblings? What was it like to be an only child?

Was your family religious or spiritual growing up? How did this impact you negatively or positively?

What was your attitude about junior high and high school growing up? What were some of the best and worst experiences from ages 13-18?

What were your biggest struggles in adolescents? How did these shape who you are today?

Dr. Ellis may reach out to you prior to the workshop if she has not worked with you before or has questions about your intake form regarding the goodness of fit for participation. Please acknowledge

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I Understand

Workshop Experience

This workshop is for those that have completed foundational personal work. It is recommended (not a deal breaker) that this not be your first intensive workshop experience. Please come resourced and ready to actively participate. The tools in this workshop we use daily and have a great impact on your nervous system. It is highly recommended you have a few days following the workshop to land back in your life.

What workshops or group experiences have you participated in?

Intensity Levels

This workshop has "optional" levels of intensity. You will be given three options of participation: 1) To observe the experience 2) To be in the experience to a modified degree 3) To be fully in the experience because your nervous system is resourced. You can change your level of intensity at anytime during the experiences. You can also take a break from the curriculum if needed. Are you comfortable with these options and do you have other needs regarding participation?

This workshop has two months of integration and an aftercare program included as part of the workshop. It is up to you the level of participation you want to participate in the aftercare program. More details about the aftercare program will be given in the workshop. Please acknowledge.

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I Understand

You can request the written agreements for the training prior to attending. Email liberationworkshops@gmail.com to request the agreements.

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I Understand

You can schedule a call with Dr. Ellis to review the curriculum by 9/10/25. There will be no curriculum content in written form prior to the workshop. Email liberationworkshops@gmail.com to set up the call.

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I understand

Trauma Informed Consent Agreement

This workshop is a trauma informed space with individual process supported by a group field. The group agreements are designed for safety, support, and optimal nervous system tracking.

Dr. Ellis includes many aspects of the trauma-informed model. However, the Liberation Workshop is NOT a replacement for mental health therapy and this workshop is not focused on treating pathology.

Liberation trainings are also not presuming to treat complex trauma or personality disorders.

If you are processing significant trauma for the first time and have not completed foundational therapy or have a severe mental illness we do not recommend this workshop at this time. Please consult your therapist/ psychiatrist to check if participating is advisable.

Please consider you are ready and capable of undertaking such focused work on the tender subject of childhood.

On that basis, Dr. Ellis acknowledges and recognizes her responsibility to offer participants nondiscriminatory care, a consent-focused space, and appropriate support concerning the process as you navigate the work.

I have read, understood, and agreed to the above terms

By clicking below you understand and agree to the above terms.

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I agree to the Trauma Informed Consent Agreement

Health Protocol

We want to remind you that you’re attending a group workshop. Illnesses are around and you are taking some level of risk of exposure. Please be mindful of yourself and others as we get closer to the workshop. I highly recommend taking immunity, boosting supplements and avoid larger group activities.

“Actively” Contagious Illness the day the training starts: cannot attend.

Illness before the training “outside of contagion” window: Can attend with mask and physical distancing while having symptoms.

Symptoms during the training: You will test for COVID as soon as possible. Our preference is to ask the ill person to wear a mask and physically distance during first few days of symptoms depending on what you have. We will do our best to assess the situation if this arises and make the most supportive decision for the health of the field.

The refund policy still applies to everyone and illnesses.

By clicking below you understand and agree to the above terms.

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I agree to the health protocol

Refund Policy

REFUND POLICY

Because we have limited space available, we have a strict refund policy.

A commitment to the Liberation Workshop is a deep commitment to yourself. It is assumed that, if you feel drawn to this workshop, it is no accident.

If for some reason you become unable to attend, we can refund a portion of your payment according to the following schedule.

Cancellation 90 Days or More Before the Event

Full refund minus $150 administration fee

Cancellation 60 - 90 Days Before the Event

Full refund minus $200 administration fee

Cancellation 30 - 60 Days Before the Event

Full refund minus $300 administration fee

Cancellation Less Than 30 Days Before the Event

No refunds, deposit and all payments are forfeited.

Once the workshop starts

No refunds, deposit and all payments are forfeited.

Signature

By signing this, you have awknowledged and agree to the refund policy.

Release of Liability

Liability Release Agreement

**PUt Julia's statement here

Signature

Agreement to ****Julia's Liability Release Form I agree, my name below is is my electronic signature to this release.

Tuition Options

Please read each question carefully. Below you will find the different tuition options. Please indicate which tuition you will be applying for.

Private Rooms

Private rooms may or may not be available at an additional cost. In the case that this becomes available, would you like us to reach out to you? This may be within a month or a few weeks of the training.

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Yes, reach out to me if a private room becomes available

No, I am fine with sharing a room

The next two questions are only if you are choosing to pay by credit card. If you are wanting to pay an alternate way, skip the next two questions, and answer the last question before you submit your application.

***If you are paying in full and paying with a credit card proceed here. If you are not, skip the next two questions.

After you submit your application, you will be redirected to pay by credit card. If you choose the last option, you will be emailed a list of links for alternative ways to pay. Please note there are additional service fees for payments. If you are not paying by credit card, skip this question.

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Early Bird-$2,100

Regular Tuition-$2,300

Repeater-$2,100

Camping-$1,900

Please click yes below if you would like to pay your deposit an alternate way. An email will be sent to you with some alternate ways to pay.

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Yes

After you submit your application and deposit, you will receive a welcome email within 10 days. The email will include additional information about what to bring, the venue, and other details about the workshop.

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