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.
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?*
Have you ever been a part of a recovery group? If so, what kind of group and for how long?*
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 pornography and masturbation

012345
Struggle with alcoholism

012345
Struggle with substance abuse

012345
Struggle with extramarital affairs

012345
How ready are you to commit to sexual integrity ("0" = I'm not ready, "5" = I'm willing to do whatever it takes)?

012345
Should be Empty: