Men’s Group Interest Form
Thank you for your interest in the Redemptive Journey Men’s Recovery Group. This form helps us learn more about you and determine the best next step. Submitting this form does not automatically confirm placement. Someone from Redemptive Journey will follow up with you.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Please Select
Email
Phone call
Text message
What city and state are you located in?
Are you interested in joining the online men’s group?
Please Select
Yes
I’m interested but have questions
I’m not sure yet
The group is scheduled for Tuesdays from 6:30–8:00 PM online. Does this time work for you?
Please Select
Yes
No
I may need to discuss it
What led you to reach out at this time?
What kind of support are you hoping to receive?
Faith-based support
Accountability
Community with other men
Help with honesty and integrity
Support around problematic sexual behavior
Support rebuilding trust
Tools for emotional growth
Other
Have you been part of a recovery group before?
Please Select
Yes
No
Not sure
Are you currently working with a counselor, coach, pastor, or mentor?
Please Select
Yes
No
I’m looking for one
Prefer not to say
Is there anything you would like us to know before we contact you?
Confidentiality Statement
Your information will be kept private and used only for Redemptive Journey follow-up and group placement. Because this is an interest form, please do not include highly sensitive details. A team member will follow up with you for next steps.
Crisis Disclaimer
If you are in immediate danger or experiencing a crisis, please call 911 or contact a local crisis hotline. Redemptive Journey will respond as soon as possible, but this form is not monitored 24/7.
I understand that this form is confidential but is not a crisis line or counseling service.
*
I agree
Submit Interest Form
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