BD - Client Application 2

What is your age range?* This field is required.

18-24

25-34

35-44

45-54

55+

What is your relationship status?* This field is required.

Single

Dating

Married

Divorced

What is your approximate annual household income?* This field is required.

Under $25,000

$25,000–$49,999

$50,000–$74,999

$75,000–$99,999

$100,000+

Prefer not to say

How would you describe your faith background?* This field is required.

Christian

Other

No faith background

In your own words, tell us a little bit about the particular issue for which you would like accountability. (Feel free to be honest with us, we have struggled with similar issues ourselves.)* This field is required.

How long have you struggled with this issue?* This field is required.

Less than 1 year

1-3 years

3-5 years

5-10 years

10+ years

Have you ever tried to stop or limit this issue on your own?* This field is required.

Yes

Which of the following have you tried? (select all that apply)* This field is required.

Willpower alone / cold turkey

Accountability app (e.g. Covenant Eyes, Accountable2You, Bark)

Content filtering software (e.g. Circle, Clean Router)

Individual therapy / counseling

Faith-based counseling / pastoral care

12-step program (e.g. Sex Addicts Anonymous)

Church-based recovery program (e.g. Celebrate Recovery, Regeneration, Walking Free, Etc.)

Online recovery program (e.g. Fortify, Relay)

Accountability partner

Support group

Other

If dating/married, how open are you with your significant other/spouse concerning this issue?* This field is required.

She does not know I struggle with this

She suspects something but we've never talked about it

She knows, but we don't discuss it

We're open about it and working through it together

N/A

Being fully transparent, how much of a problem would you say this issue is in your life right now?* This field is required.

I have it mostly under control

It comes and goes but I'm managing

Its a significant struggle that's affecting my life

My life is in shambles and I need help

Have you ever had a dedicated accountability partner specifically for this struggle?* This field is required.

Yes

If your accountability partnership failed or fell short, what was the biggest reason?* This field is required.

Inconsistency

Lack of commitment from partner

Uncomfortable sharing

Didn't know what to do

N/A

Other

Brave Disciple provides consistent and committed accountability partnerships with partners who have faced similar struggles firsthand. We are not a standalone solution, but part of a broader system which also includes community and structured programming to help you overcome this issue. Are you currently enrolled in any program or receiving help for this issue?* This field is required.

Yes

Would you be open to joining a program of your choice (online, in-person, etc.) to assist you with this issue?* This field is required.

Yes

Additionally, are you part of a caring community that could support you in this effort? (e.g. church, small group, friends, family)* This field is required.

Yes

Somewhat

No, but open to finding community

As part of our partnership program, Brave Disciple requires full commitment to our accountability process. Please confirm your willingness to do the following: Are you willing to have your devices monitored and filtered as part of the accountability process?* This field is required.

Yes

Are you willing to be fully transparent with your accountability partner, even when you fall short? (We understand stumbling is a part of the process and will provide support to restore and continue on the path to recovery)* This field is required.

Yes

Are you willing to commit to regular check-ins as part of the partnership?* This field is required.

Yes

Finally, would you be interested in participating in a community with other guys seeking to recover from similar struggles?* This field is required.

Yes

Name* This field is required.

First Name/Alias

Last Name

Email* This field is required.

example@example.com

Phone Number

Please enter a valid phone number (optional)