Wholeness Intensive Registration

Application for The Wholeness Intensive

Thursdays starting January 2, 2024 at 7pm CST | Enroll by December 26, 2024
Full Name*

First NameLast Name
Phone Number*
Can you receive texts on this phone number? *

YesNo
E-mail*

Confirmation Emailexample@example.com
Location (City/State)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Can I share your information with other group members?*

Yes! Email, Phone #, and City/StateYes! Email OnlyYes! Phone # OnlyYes! City/State OnlyNo, I will share with the group when I am more comfortable later
Address to ship 90 Days to Wholeness paperback (ships to United States only). Must apply by December 20, 2025 to guarantee delivery by start date.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Application
Occupation
Birthdate*

MonthDayYear
Martial Status*
Do you have children?*

Yes, and they live with me.Yes, but they don't live with me.No
Briefly describe your life story to date. Share as little or as much background information as you would like. *
Please briefly describe why you are seeking these services and what you hope to achieve? Please be as specific as you can.*
Are you now or have you ever been in counseling or therapy? If yes, please explain.*
Have you ever been coached before? If so, was your prior experience like? If not, please type N/A.*
Have you ever attending a recovery group for sexual wholeness before? If so, what was your prior experience like? If not, please type N/A.*
Describe your faith. What is your relationship with God like? In what ways do you sense He might be challenging you, nudging you, or trying to get your attention?*
What are some major things happening in your life right now?*
How would you like your life to be different one month from now? One year from now? Five years from now?*
What is getting in the way of achieving these changes or goals?*
Name 3 things in your life you are procrastinating on in your life right now.*
If we worked together in this intensive, in what ways might you sabotage us as your facilitators or your own success? In what ways can we help you to not do this? *
What are some of your concerns or insecurities about being in this intensive?*
Are you already a member of the SheRecovery Community Facebook community?*

YesNo, please send me an invite
Are you already a SheRecovery Member?*

Yes, please waive my monthly payments during intensiveNo, please send me the member portal invitation
Is there anything else you would like to add?
Terms & Agreement

By submitting this application you are agreeing to the following terms. Please read carefully and check the individual boxes to agree to the terms.
I agree to all terms as outlined below:*

I understand that Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore are not licensed counselors.I understand Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore hold no responsibility for any harm I may cause to myself or others.I understand that Crystal, Kimberly, and Stephanie agree to keep all information I disclose in group or individually strictly confidential, except in situations that violate the law or harm to self or others is disclosed.I understand that Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore will assign homework and failure to complete homework could result in termination of remaining sessions and without refund.I understand that each weekly group session will be 2.5 hours in length held every Thursday between January 2, 2025 and March 27, 2025. Adjustments to the schedule will be communicated with adequate warning.I understand that if I am unable to attend pre-paid sessions, no refund will be provided. If extenuating circumstances apply, they will be considered on a case by case basis.I understand that if I miss more than two group sessions without notice, I will forfeit my place in the group without refund.I understand that a lack of communication on my part with Crystal, Kimberly, or Stephanie (i.e. not responding to emails and texts and/or not showing up to sessions) will be interpretted as a withdrawal from group and no refund will be provided.I understand that I will receive three (3) individual sessions as part of this intensive that will allow me to meet once individually with Crystal, Kimberly, and/or Stephanie (one session per facilitator).I understand that each individual session will last 60 minutes and will be on a specific date and time we schedule together. Being late to the individual session will cut into my total session length.I understand that the individual sessions expire on April 10, 2025 and I will not be refunded for unused sessions.I understand that as part of the intensive, I am required to attend at least one additional SheRecovery Meeting each week AND post daily in the Intensive YouVersion group to show I have done the required reading each day.I understand in order to receive my paperback book on time for the January 1, 2025 start date, I need to have applied by December 20, 2025. After December 22, I may receive my book late.
- I understand that Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore are not licensed counselors.
- I understand Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore hold no responsibility for any harm I may cause to myself or others.
- I understand that Crystal, Kimberly, and Stephanie agree to keep all information I disclose in group or individually strictly confidential, except in situations that violate the law or harm to self or others is disclosed.
- I understand that Crystal Renaud Day, Kimberly Johnson, and Stephanie Madore will assign homework and failure to complete homework could result in termination of remaining sessions and without refund.
- I understand that each weekly group session will be 2.5 hours in length held every Thursday between January 2, 2025 and March 27, 2025. Adjustments to the schedule will be communicated with adequate warning.
- I understand that if I am unable to attend pre-paid sessions, no refund will be provided. If extenuating circumstances apply, they will be considered on a case by case basis.
- I understand that if I miss more than two group sessions without notice, I will forfeit my place in the group without refund.
- I understand that a lack of communication on my part with Crystal, Kimberly, or Stephanie (i.e. not responding to emails and texts and/or not showing up to sessions) will be interpretted as a withdrawal from group and no refund will be provided.
- I understand that I will receive three (3) individual sessions as part of this intensive that will allow me to meet once individually with Crystal, Kimberly, and/or Stephanie (one session per facilitator).
- I understand that each individual session will last 60 minutes and will be on a specific date and time we schedule together. Being late to the individual session will cut into my total session length.
- I understand that the individual sessions expire on April 10, 2025 and I will not be refunded for unused sessions.
- I understand that as part of the intensive, I am required to attend at least one additional SheRecovery Meeting each week AND post daily in the Intensive YouVersion group to show I have done the required reading each day.
- I understand in order to receive my paperback book on time for the January 2, 2025 start date, I need to have applied by December 22, 2025. After December 22, I may receive my book late.
Payment & Payment Plans

Choose Coaching Payment Plan*

13-Week Payment Plan$125 for Week 1 due now. Then 12 weekly payments of $125 starting Week 2 on January 9, 2025.

$125.00

3-Month Payment PlanMonth 1 due now. Months 2 & 3 due January 30, 2025 and February 27, 2025.

$540.00

Pay in FullPayment due in full now.

$1,625.00

Enter coupon

Total

$0.00

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Application for The Wholeness Intensive

Application

Terms & Agreement

Payment & Payment Plans