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Support Group Intake Form
Support Group Intake
Step
1
of
4
25%
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
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
Country
Primary Phone
*
Can you receive last minute communication via text at this number?
*
Yes
No
Current Marital Status
*
Never Married
Domestic Partnership
Engaged
Married
Married/Separated
Divorced
Widowed
What group are you planning to attend?
*
Please select...
Online - Seeking Hope
Online - Finding Hope Group (Evening)
Online - Finding Hope Group (Daytime)
Online - Triad Coaching
Online - Boundaries Group
Online - Living In Hope
Local Group
Other
How long since discovery/disclosure?
When was your divorce final?
*
MM slash DD slash YYYY
Your Husband/Partner
Is your husband/partner currently working on his recovery?
*
Yes
No
Maybe
Is he attending a 12-step program?
*
Yes
No
Maybe
Does he stuggle with any other substances use disorders or mental illness?
*
Previous Support
Have you been involved in other support groups for sexual addiction/betrayal trauma?
*
Yes
No
Maybe
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?
*
Yes
No
Please describe your counseling experience and the support you received.
*
About You
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?
Confidentiality Agreement
*
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:
• 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 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.
Local Contact
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?
Yes
No
Unsure
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
*
ONLINE ONLY:
Our groups are recorded. These recordings are stored in a protected online google doc and 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:
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 support@hoperedefined.org
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