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Support for Women
Why Support for Women
Statement of Faith
Support for Women
Why Support for Women
Statement of Faith
Support Group Intake Form 2RC
Intake form Healing for Wives
Welcome to the Healing For Wives Support Groups hosted at Two Rivers Church. Please complete this form if you will be participating in our in person group. 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. If you are not comfortable answering a question - skip it. No pressure. We are honored to walk with you as we all run hard after our healing.
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Can you receive last minute communication via text at this number?
Current Marital Status
How long since discovery/disclosure?
Is your husband/partner currently working on his recovery?
Is he attending a 12-step program?
Does he stuggle with any other substances use disorders or mental illness?
Have you been involved in other support groups for sexual addiction/betrayal trauma?
If yes or maybe, please describe ways the group was helpful:
Please describe the group (support group? study group? What were the strengths of the group? What did you gain? What were the weaknesses?)
Have you worked with a professional counselor/Biblical counselor?
Please describe your counseling experience and the support you received.
How would you describe your spiritual life?
Describe what "self-care" means to YOU. What brings you JOY? How do you practice self-care? How often do you practice self-care?
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 is:
• 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 the intensive retreat and/or am a part of 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
Does your pastor know that you are attending a support group?
I would prefer them not know
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
Hope Redefined Group Guidelines
These are our group guidelines. These are put in please to allow for the best group experience for everyone participating in the group. These guidelines also help to manage expectations and group dynamics well.
Consent to Group Guidelines
OUR AGREEMENT WITH ONE ANOTHER:
1) It’s About Me: Keep your focus on your thoughts and feelings. We work in 1st 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.
2) 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
3) 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.
4) 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.
5) 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.
Is there any group guideline or rule you would like to see implemented for our group? (Please share below.)
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 firstname.lastname@example.org
I'm interested in:
Online support groups
Therapeutic Disclosure Support
Connecting with ministry