Achim Bederech

A seven week, in-person program, for men to integrate previous medicine journeys into daily life.

This application has been created so that we might better understand you and your needs. All the information shared on this form will remain completely confidential. Thank you for your trust in us and your interest in the program. Start Date: Jan 18th 2026 Location: Airmont & Pomona, NY

Reserve your spot.

First name

Last name

Phone

Age

Marital Status

Married

Divorced

Single

Other

What do you hope to achieve with this program? (Be as specific as possible. Your answers are confidential)

Have you ever participated in similar events? If your answer is no, why have you decided to participate now?

What would make this program a successful experience for you?

Do you have any medical conditions (mental and/or physical) that we need to be aware of?

Are you taking any prescription medications?

Were you referred by someone?

Do you commit to respecting the group and keeping confidentiality?

Are you ready to invest in yourself?

Time

Money

Energy

Discomfort Necessary To Grow

Get Ready To Take Life To The Next Level!

Achim Bederech

Reserve your spot.

Get Ready To Take Life To The Next Level!

Schedule a time to Talk with Berry Nash