Riverbend Sexual Recovery Intake Questionnaire

Riverbend Sexual Recovery Intake Questionnaire

Please tell us a little about yourself. All of this information is completely confidential, and is solely for the purpose of helping the facilitators place you in the best group, as well as for your own self reflection. Thank you for your courage and vulnerability. We hope to begin this healing journey alongside you.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Why are you interested in our Pure Desire Groups?
Briefly describe your current unwanted sexual behavior
Does your partner know any part of your sexual integrity challenges?
Have you ever been a part of a recovery group? If so, what kind of group and for how long?
Is there a possibility of legal ramifications from your acting out?

Other
Rate yourself on a scale of 0 to 5. 0 means "no problem," 5 means "it's causing significant challenges in your life."
Struggle with alcoholism
Struggle with substance abuse
Struggle with extramarital affairs
How ready are you to commit to sexual integrity ("0" = I'm not ready, "5" = I'm willing to do whatever it takes)?
Should be Empty: