Boundaries Intake Form

Boundaries Group Intake Form

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Welcome to Hope Redefined Support Groups. This form should be completed if you will be participating in ANY online support group with Hope Redefined or the local support group, Healing for Wives in Knoxville, TN. 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*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Can you receive last minute communication via text at this number?
- Yes
- No
Current Marital Status
- Never Married
- Married
- Domestic Partnership
- Divorced
- Currently Separated
- Widowed
How long since discovery/disclosure?
Is your husband/partner in recovery?
- Yes
- No
- Unknown
Is he currently working?
- Yes
- No
- Unknown
Is he attending a 12-step program?
- Yes
- No
- Maybe
- Other
Does he stuggle with any other substances use disorders or mental illness?
Have you been involved in other support groups for sexual addition/betrayal trauma?
- Yes
- No
- Maybe
If yes, please describe ways the group was helpful:
Please also indicate if any of your groups or support were connected to Hope Redefined.
Please describe the group (support group? study group? What were the strengths of the group? What did you gain? What were the weaknesses?) Please feel free to put n/a if you have not participated in a group.
How would you describe your spiritual life?
How did you learn about this support group?
What do you hope to get out of this support group? What are you most looking forward to?
What's your biggest fear starting this group?

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. We commit to creating a safe place for those who come to share their story. When you leave at the end of each session and upon completion of the group, who you have seen here and what you have heard stays here. Don’t talk about it. Period. No exceptions. Additional steps to ensure confidentiality for all group member are: To please wear earbuds or headphones during the calls or while listening to a recorded call. This is to ensure that only YOU can hear the group conversations and not by standers or house guests. Please do not provide an email address that is shared in your home. We ask for communications within the group to be held confidential and private as well. If you need to change your email address to a private email address, please contact the facilitator prior to group. (This applies to those who might share an account with a spouse, children, or family email account). 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 a Hope Redefined support group (i.e.“I am participating in a support group on Tues nights with Hope Redefined.”)
Please check if you have READ and AGREE with our confidentiality agreement.
In order to ensure the highest level of safety please provide us with local contacts.
Your Church Name/Affiliation
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
Please provide your Pastor's name (or other)
Pastor's Phone Number (or other)
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.
Emergency Contact & Relationship*
Emergency Contact Phone*

These are our group guidelines. These are put in place to allow everyone participating in the group to have the best experience. These guidelines also help manage expectations and group dynamics.
ONLINE ONLY: Our groups are recorded. These recordings are password protected and stored within our Vimeo account. All recordings are destroyed once the group is complete. If you have a concern about our calls being recorded, please contact the group facilitator ahead of time. We will discuss alternate options. OUR AGREEMENT WITH ONE ANOTHER: * It’s About Me: Keep your focus on your thoughts and feelings. We work in first person (I, me). We DO NOT husband bash. (Let no corrupt talk come out of your mouths, but only such as is good for building up, as fits the occasion, that it may give grace to those who hear [Ephesians 5:29].) This is a safe place to do healthy venting, but we cannot permit slander or bashing of another person. * Blessed are the Brief: We are committed to respect, mutual support, being safe, and genuine sharing. We desire to include all group members, so please limit sharing to 3 minutes so that everyone gets a chance to participate. Trust the Wonderful Counselor: We are here to support and encourage one another as we each seek God’s direction for our lives and marriages. We are NOT here to “fix” one another. Please avoid offering advice and solutions to others. Empathy is welcome, but we aren’t the Wonderful Counselor—the only One who can fix broken relationships. Practice Active Listening: There should be no crosstalk, please. Crosstalk includes interrupting, asking prying questions, or engaging in any back-and-forth conversations while a member is in the process of sharing. Safety First: If we are concerned that you are at risk of hurting yourself or others, we will approach you and will advise outside counsel of the situation. If we are concerned that others might be hurt around you (not because of you) we are required to report this to appropriate authorities. However, we will not do this without discussing with you first.
*
I have read and agree to the GROUP GUIDELINES laid out above.
Are there any group guidelines or rules you would like to see implemented to help with the group's safety?
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.

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