Betrayal and Beyond Intake Form

Betrayal and Beyond Intake Form

Please fill out the information below and leave this form on the table. We will collect it at the end of the night and be in touch with you regarding next steps!-Kristianna, Marcy, Sara and ChloeYour Riverbend B&B Support Team
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Do you have kids? If so, please list ages.
For you to be able to attend a group, is childcare a must have, a ‘nice to have’, or not necessary?
As our team prayerfully considers which group time to start first, or whether we have enough interest to start both simultaneously, we greatly value your feedback! * If your schedule could at all possibly allow, please select both options. * What is your availability? (Please check one or both below)

Sunday Nights, 5:30-7:30 PM, Riverbend ChurchTuesday Mornings, 9:30-11:30 AM, Riverbend Church
What is your significant other's' name?
What’s your current status: Married? Engaged? Dating? Separated?
In a couple sentences, please share what happened to you, and where you find yourself today, in light of betrayal? *Answering is totally optional*
*In addition to joining a group, if you are in need of expanding your network of care-(counselor/coach, pastoral direction, mentor) please visit https://riverbendajc.org/sexualformation; and contact our team if you need assistance with referrals or resources. We are here for YOU!*
Now that you’ve gotten a chance to hear a little more about the group process, please indicate your readiness and capacity for committing to a group by checking the most applicable answer below:

“Yes, count me in, I’m ready to go ASAP.”“Yes, count me in, but I may need to join a group that starts in a few more months.”“Group sounds great, but it is not the right time or not the best fit for me currently. I will reach out to the support team in the future, if needed.”
Should be Empty: