Bridge Back to Us Application
Complete All Sections Below
Spouse 1
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse 2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What time zone are you in?
Pacific
Mountain
Central
Eastern
Other
Relationship Status:
Married & Living Together
Married & Separated
Engaged
Dating
If married, how long have you been married?
1-5 years
5-10 years
10+ years
How old are you?
Less than 25
26-35
35-45
45+
How did you first hear about R2M?
When was your Discovery Day? ( day you found out about pornography, affair, addiction, etc.)
-
Month
-
Day
Year
Date
UNFAITHFUL SPOUSE SECTION: What is your biggest struggle right now?
Relapse, learning how to be free from addiction
Communication with your spouse
Lack of empathy for your spouse
Walking on egg shells
Lack of support from other men
Have you started recovery?
Please Select
yes
no
If so, how long have you been in recovery?
Less than 1 year
1-5 years
5-10 years
10+ years
Courses/Programs you have previously done:
Are you currently seeing a professional counselor or therapist?
Please Select
yes
no
Did you act out sexually outside of pornography and masturbation?
Please Select
yes
no
If yes, have you disclosed these actions to your spouse?
If yes, what other forms of sexual behaviors have taken place during your marriage?
Has there been a relapse in the last 90 days?
Please Select
yes
no
How long has it been since your last relapse?
What is the longest amount of time you have gone without the use of pornography?
Has there been any use of child pornography?
Please Select
yes
no
Has there been any form of child molestation involved in your acting out?
Please Select
yes
no
Do you struggle with thoughts of suicide?
Please Select
yes
no
Have you surrendered your life to Jesus Christ as your Lord and Savior?
On a scaled of 1-5 (5 being the highest) how active are you in attending church, scripture reading, or serving at your local church? Explain further if needed.
Explain your relationship with Jesus right now (examples: very close, distant, angry at God, confused, hurt, not super deep, etc.)
On a scale of 1-5 (5 being the highest) how eager are you to start the restoration journey?
Are you willing to be relentlessly honest with this group even when it is uncomfortable?
Please Select
yes
no
Are you willing to do the necessary work to find freedom?
Please Select
yes
no
Back
Next
BETRAYED SPOUSE SECTION: What are your biggest struggles right now?
Communication about recovery process
Understanding your spouses pain and struggle
Rebuilding trust in the relationship
Safety in the relationship
Walking on egg shells to avoid triggering one another
Constant anger
Investigator Syndrome
Other
Have you started recovery?
Please Select
yes
no
How long have you been in recovery?
Less than 1 year
1-5 years
5-10 years
10+ years
Courses/Programs you have previously done:
Are you currently seeing a professional counselor or therapist?
Please Select
yes
no
Do you struggle with thoughts of suicide?
Please Select
yes
no
Have you surrendered your life to Jesus Christ as your Lord and Savior?
On a scaled of 1-5 (5 being the highest) how active are you in attending church, scripture reading, or serving at your local church? Explain further if wanted.
Explain your relationship with Jesus right now (examples: very close, distant, angry at God, confused, hurt, not super deep, etc.)
On a scale of 1-5 (5 being the highest) how eager are you to start the restoration journey?
Are you willing to be relentlessly honest with this group even when its uncomfortable?
Please Select
yes
no
Are you willing to do the necessary work to find healing and restoration in your relationship?
Please Select
yes
no
Submit
Should be Empty: