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Home
Support for Women
Why Support for Women
Meet Our Coaching Team
Online Groups
Retreats
Online Community
Webinars
Therapeutic Disclosures
Resources
Blog
Podcasts
Gardens and Grace Coloring Book
About Us
Our Story
Staff
Board
Statement of Faith
Ministry Updates
Join The Team
Shop
Donate
Stones of Hope
Donate Now – Partner with Us
Contact Us
My Account
Welcome!
Welcome to the Redeemed Hope Intensive Healing Retreat. We are so glad you have registered and decided to make this step into your next chapter of healing. Please take some time to complete the intake form. This form is held confidential and will only be used to serve you and your needs better. If this form misses a detail that you need to share please feel free to contact Lyschel Burket at support@hoperedefined.org.
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Birth Date
(Required)
Month
Day
Year
Age
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Which retreat will you be attending?
(Required)
Spring 2025
Fall 2025
Present Occupation
Current Marital Status
(Required)
Never Married
Domestic Partnership
Engaged
Married
Married/Separated
Divorced
Widowed
Other
With whom are you currently living?
(Required)
Does your husband (ex) know you are attending this retreat?
(Required)
Yes
No
Unsure
Do you have children?
(Required)
Yes
No
Unsure
Please share your children's gender and age: (M 20, F 17)
(Required)
What has prompted you to seek healing from sexual betrayal?
(Required)
What are your greatest needs at this time?
(Required)
What is your biggest concern or fear coming into this retreat?
(Required)
Personal Health Inventory
In this section, you will share your personal health inventory. We ask these specific questions to ensure quality of care for each participant at the retreat.
How would you rate your physical health? (1 poor – 5 excellent)
(Required)
How would you rate your spiritual health? (1 poor – 5 excellent)
(Required)
How would you rate your emotional health? (1 poor – 5 excellent)
(Required)
How would you rate your mental health? (1 poor – 5 excellent)
(Required)
Have you experienced or are you experiencing any symptoms such as: depression, anxiety, bi-polar, PTSD, ADD/ADHD? (Please share all that you have experienced.)
(Required)
Have you been given a diagnosis of mental illness from a professional? (If yes, please explain.)
(Required)
Are you currently taking any medications or supplements to address this mental illness?
(Required)
* If you are currently taking any medication please DO NOT stop taking unless directed by your health care provider.
Yes
No
Are you currently working with a coach/therapeutic/licensed professional?
(Required)
IMPORTANT: Please complete a Release Of Information form for your professional.
Yes
No
Feel free to explain any of your answers from the above personal health inventory questions:
Recovery Work
In this section we would like to learn about the recovery work done so far. We will ask you to share both your personal recovery work and your husband's.
How long since discovery/disclosure?
(Required)
Are YOU currently or in the past: (check all that apply)
(Required)
Seeing a therapist/coach
Attending 12 step group (SA-no, AI-non, CR)
Support Group for Spouses
Other
Please describe YOUR support system. (i.e. family, friends, church, therapist, etc).
(Required)
Is HE currently or in the past: (check all that apply)
(Required)
Seeing a therapist
Attending 12 step group (SA-no, AI-non, CR)
Accountability from someone other than spouse
In a mentor relationship with someone in the church
Inpatient Treatment
Other
Have you shared your story/marriage struggles with others before? If so, please explain what that was like for you
(Required)
More Info
Dietary Needs
(Required)
Please share any dietary needs that you have while we serve you this weekend. (allergies, avoidance)
Gluten Free
Dairy Free
Vegetarian
None
Other
Please explain any specifics to your dietary needs.
Do you have any physical needs that need to be met while at the retreat? (accommodations for sitting, sleeping)
Emergency Contact Name
(Required)
Please provide the name of an emergency contact we may use while you're at the retreat.
First
Last
Emergency Contact Phone
(Required)
Relationship with Emergency Contact
(Required)
Spouse/Partner
Mom
Dad
Friend
Other
Confidentiality Agreement
(Required)
Your communications with Hope Redefined are confidential. The leadership will not release any information without your signed written release. You should also be aware that under some circumstances, your confidentiality may be waived. These circumstances include: threats or acts of harm to yourself or others and abuse of a child in any way. A special clarification for group work is also necessary.
Confidentiality of group members’ communications and information by other group members is not protected by law. However, each group member must be committed to confidentiality to make a safe environment to share openly.
I understand that I am not to disclose to anyone outside the group (especially my spouse, friends, coworkers, pastors, etc.) any information that may identify another group member. This includes, but is not limited to, names, physical description, biographical information, and specifics of content of interactions with other group members. I understand that I am free to disclose to people I choose the fact that I attended the intensive retreat and/or am a part of Hope Redefined.
I have read and agree with the Confidentiality Agreement.
Cancellation and Payment Policy
(Required)
REFUND POLICY
– Full refund is available up to 46 days pre-retreat
– 50% refund (excluding deposit) available 45 days pre-retreat
– No refund available 30 days pre-retreat (participate is able to transfer reservation to next retreat)
PAYMENT POLICY
– Deposit will secure your spot for the retreat
– Final payment for retreat fees are due 30 before retreat.
– If final payment is not made 30 days pre-retreat participants spot will be made available again and no refunds will be issued.
I have read and understand the cancellation and payment policy.
Release for Participation
(Required)
In exchange for participation in the REDEEMED HOPE RETREAT (the “Activity”), organized by, HOPE REDEFINED, located in Knoxville, TN (“Releasee”), I hereby agree as follows:
1. I and anyone claiming on my behalf release and forever discharge Releasee and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from causes of action of any nature and kind, known or unknown, which I may have against Releasee or any Released Parties arising out of or relating to any injury, loss or damage to person and property that may be sustained as a result of participation in the Activity (“Claims”).
2. I understand that participation in the Activity involves inherent risks, including risk of physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent paralysis and/or death, and I assume all related risks and voluntarily participate in the Activity.
3. I agree to indemnify Releasee against any and all claims, actions, lawsuits, damages and judgments, including attorney’s fees, arising out of or relating to my participation in the Activity.
4. This Release for Participation in Event or Activity (“Release”) shall not be in any way construed as an admission by the Released Parties that it has acted wrongfully with respect to me or any other person, that it admits liability or responsibility at any time for any purpose, or that I have any rights whatsoever against the Released Parties.
5. This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. I have the authority to release the Claims and have not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the State/Commonwealth of Tennessee.
I have carefully read and fully understand all the provisions of this Release and am freely, knowingly and voluntarily entering into this Release by checking the agreement and providing my name and address below.
I agree with this Release for Participation presented by Hope Redefined. My name and date below will be representative of my signature and agreement.
Photography and Video Permissions
I agree to allow Hope Redefined to use my face in internal photos or videos within the community of Hope Online.
Assumption of the Risk & Waiver of Liability Relating to Coronavirus/COVID-19
(Required)
The coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. It is recommended by the Tennessee Pledge that the groups follow social distancing guidelines and wear face masks.
Hope Redefined has put in place preventative measures to reduce the spread of COVID-19 during the upcoming Redeemed Hope Weekend Retreat (the Retreat). However, Hope Redefined cannot guarantee that you will not become infected with COVID-19. Further, attending the Retreat could increase your risk of contracting COVID-19. Note: Preventive measures shall include, but not be limited to: 1) hand-sanitizer and disinfectant wipes shall be made readily available; 2) masks and gloves available for those who desire to utilize them; 3) diffusing of antibacterial ionic misters to capture germs 4) particular efforts to provide social distancing during hours of sleep; 5) careful attention to handling of meal prep and service; 6) a brief symptom evaluation will be taken upon arrival and possibly during the Retreat.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending the Retreat and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Retreat may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Redeemed Hope team members and guests.
By signing below I also agree that in the last 21 days I HAVE NOT: 1) tested positive or presumptively positive with the Coronavirus nor have I been identified as a potential carrier of the Coronavirus; 2) experienced any symptoms commonly associated with the Coronavirus; 3) been in any location positively designated as hazardous and/or potentially infected with the Coronavirus by a recognized health or regulatory authority; 4)been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the Coronavirus or who has been identified as a potential carrier of the Coronavirus.
I AGREE to notify Hope Redefined (by email to Executive Director, Lyschel Burket at LyschelBurket@HopeRedefined.org) of any change in status, including diagnosis with Coronavirus and/or quarantine, within thirty (30) days either before or following the Retreat. I also AGREE to consent to having my temperature taken by a Redeemed Hope representative upon arrival and possibly during the Retreat. In becoming symptomatic (fever) I will agree to leave the retreat facility, and seek medical attention immediately.
I ACKNOWLEDGE & ACCEPT that this Declaration shall be governed by the laws of Tennessee. I irrevocably agree that the competent Courts of Tennessee shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts. Nothing contained herein shall limit the right of Hope Redefined to take proceedings in any other Court of Competent jurisdiction nor shall the taking of proceedings in any other jurisdiction whether concurrently or not one or more jurisdiction preclude the taking of proceedings in any other jurisdiction whether concurrently or not.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at the Retreat. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Hope Redefined, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Hope Redefined, its volunteers, employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Hope Redefined activity.
Confidentiality of group members’ communications and information by other group members is not protected by law. However, each group member must be committed to confidentiality to make a safe environment to share openly.
I understand that I am not to disclose to anyone outside the group (especially my spouse, friends, coworkers, pastors, etc.) any information that may identify another group member. This includes, but is not limited to, names, physical description, biographical information, and specifics of content of interactions with other group members. I understand that I am free to disclose to people I choose the fact that I attended the intensive retreat and/or am a part of Hope Redefined.
I have read and agree to this COVID waiver.
Is there anything else you'd like to add?
Please attach a photo.
This will allow us to "see" you when we pray for you before we meet you face-to-face.
Max. file size: 64 MB.
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