Name of Group
Day of the week when the group meets
Time of the day when this group meets

Welcome!

Welcome to Hope Redefined Support Groups. This form should be completed if you will be participating in ANY online support group with Hope Redefined. This form is to help us, the group facilitators, get to know you better prior to the group starting. Your responses will remain confidential and will only be shared with the group facilitator.
Name(Required)
Address
Which race or ethnicity best describes you? (Please choose only one.)
Current Marital Status

Your Husband/Partner

Current Marital Status
Is your husband/partner currently working on his recovery?
Is he attending a 12-step program?

Previous Support

Have you been involved in other support groups for sexual addiction/betrayal trauma?
Have you worked with a professional counselor/Biblical counselor?

About You

Local Contact

In order to ensure the highest level of safety please provide us with local contacts.
Name of a Contact at Church
If your pastor does not know you personally please provide us with someone in your church that does know you personally. Example: Women's Pastor, Church Counselor, Small Group Leader
Example: Women's Pastor, Church Counselor, Small Group Leader
Does your pastor know that you are attending a support group?
Please understand we will not be directly contacting your church for any reason other than the concerns outlined in the confidentiality agreement. We will also notify you prior to contacting someone on your behalf.
Name of Emergency Contact(Required)
Relationship with Emergency Contact(Required)

Hope Redefined Group Guidelines

Clear Signature

Your Intake Form is Complete

​ Thank you so much for completing our intake documents. We are very excited to begin this healing journey with you. You will receive communications through email or Hope Online in the weeks leading up to the start date of your group. If you have any questions please contact support@hoperedefined.org

Contact Us

Name(Required)
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