FMM Affiliate Recovery Coaching Application

Recovery Coaching Application

ENVIRONMENTAL SITUATIONS / INFLUENCES

RELATIONAL

Select N/A if never married

Recovery Coaching Application

Second Chance Consults, FMM Affiliate, Africa - Kenya
Forgiven Much Ministries’ Affiliate Recovery Coaching is led by facilitators who are trained and supervised by a Certified Pastoral Sexual Addiction Specialist (CPSAS), ensuring both professional-level insight and biblical guidance.
Name

First NameLast Name
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please list your emergency contact with phone number and your relationship to them.
Email
example@example.com
May we send FMM's quarterly newsletter or other information to your email?
Which support group are you interested in attending?
What time zone do you live in?

What is your availability for recovery coaching? (select all that apply)

What is your age range?
Are you currently in counseling or have you been in counseling?
If yes, who is your counselor and where are they located?
Have you been in a support group before?
Are you a professing believer in Jesus Christ?

Other
Are you attending church fellowship?

Other
What is your relationship status?
Total # of Marriages
Total # Years Married
Regarding your current marriage, how many years have you been married?
How many years have you been divorced?
Total # of Children
# of Abortions
Regarding the addict's recovery, are they/you:
Regarding the spouses recovery, are they/you:
Areas that you are seeking help or instruction for: (Select all that apply)

Other
ENVIRONMENTAL SITUATIONS / INFLUENCES
Social Media / Apps (Select all that apply)

Other
Streaming platforms:

Other
Streaming Restrictions or Permissions applied to devices:

Other
RELATIONAL
How many minutes a day do you have without devices?
How many days a week do you have a meal with someone?
Select N/A if never married
How regularly did/do you have intimate/vulnerable conversations with your spouse?
Did/Do you withhold love from your spouse?

Other
Did/Do you withhold praise or appreciation from your spouse?

Other
Did/Do you control with silence or anger?

Other
Did/Do you use ongoing or ungrounded criticism causing isolation?

Other
Did/Do you withhold sex from your spouse?

Other
Were/Are you unwilling or unable to discuss feelings with your spouse?

Other
Did/Do you stay so busy that there is no relational time for your spouse?

Other
Did/Do you create problems or issues about your partner instead of owning your own issues?

Other
Did/Do you control or shame your partner with money issues?

Other
How often do you have spiritual or Bible study conversations with others?
What does your personal prayer/devotional/quiet time look like?
How often do you manage your emotions?
Do you provide enough margin in your schedule for interruptions?

1

2

3

4

5

1 is No, things are pretty tight, 5 is Yes, I'm pretty flexible
Scale your current practice regarding deep inner reflection

1

2

3

4

5

1 is Not very introspective, 5 is Very introspective
What would you like us to know about your experience regarding sexual integrity?
Should be Empty:

Mid-Late Mornings

Early afternoons

Late afternoons

Early evenings

Late evenings