woMen’s Recovery Intake form

Please complete this information form completely. We will contact you soon.

Your Information

Name(Required)
Mailing Address (for curriculum purposes)(Required)
Are you currently a member of an Apostolic church that upholds the doctrine of one God, baptism in Jesus' name, and teaches the receiving of the Holy Spirit?(Required)
Are you the current or former spouse of an individual who is dealing with or recovering from a sex or pornography addiction?(Required)
Have you and your spouse had a full disclosure regarding your spouse's behavior while in active addiction?(Required)
Are you able to commit to participating in weekly Zoom meetings (with camera on) for a minimum of one and a half hours, along with completing daily assignments and engaging in regular check-ins?(Required)
Are you currently seeing a counselor?(Required)
If no, do you plan on pursuing counseling? *(Required)
Are you at a time of great stress or important transition in your life? (ex. pregnant, job change, moving homes, etc).(Required)
I acknowledge that the cost of the recovery program is $600 plus curriculum fees, with a discounted rate of $500 available if paid in full upfront rather than on a monthly basis.(Required)

Recovery Group Consent