If you are married, we strongly urge you and your spouse/partner to participate in Intensive. Each partner must complete an application.

Please note: Our goal is to make sure a Three-Day Intensive is the appropriate course of treatment for an individual or a couple. By completing this application, you can help us determine if this is the appropriate treatment for you.

Submitting an application DOES NOT obligate you to participate in an intensive. All couples who want to be considered for an intensive will need to make application as part of our careful screening process. (This application may also be completed by phone.)

Name:

Date:

City:

State:

Age Today:

Best Phone number to contact you:

Best e-mail address to reach you:

Would you like to receive Hope & Freedom’s e-mail newsletter?

Marital status:

How long have you been in your current relationship?

Previous Marriages:

Self:

time(s)

Spouse:

time(s)

Spouse’s/partner’s name:

Partner's age:

Number of Children:

Self?

Spouse?

Occupation (self):

Occupation (spouse):

How would you describe your current work situation?

How would you describe your spouse’s current work situation?

Have you done any previous work in recovery from compulsive sexual behavior?

Are you currently seeing a therapist?

Have you seen a therapist in the past?

Do you believe you may have other addictions?

Please indicate which other addictions you currently have or have struggled with in the past:

Co-Dependency

Alcohol

Drugs

Gambling

Video Games

Other Internet Related Compulsive Behaviors

Eating Disorder

Compulsive Spending/Shopping

Other Addiction (Please specify)

Have you ever thought about taking your life?

Details:

Have your ever attempted to take your life?

Details:

Do you currently attend 12-step meetings?

Fellowship? (which organization)

Number of meetings a week?

If you do not currently attend 12-step meetings, have you ever attended 12-step meetings?

If yes, number of meetings per week:

Our recovery program incorporates 12-step meetings as part of the overall recovery plan. Are you willing to attend 12-step meetings as part of your recovery?

If not, please explain:

One of the major goals of Intensives it to see marriages/relationships restored. Our Intensives are designed to help move couples toward a total restoration of trust and fidelity. Because Intensives dig deeply to the root of the addiction and will often uncover long-held secrets, we require couples to make an unqualified, unreserved commitment to remain in the marriage after the Intensive. For the partner, we require that commitment to be for a minimum of 12 month after the intensive. For the sex addict we require the same type of commitment but for 24 months after the Intensive. Do you agree to abide by this requirement?

We ask that participants not drink any alcohol for at least 30 days prior to the intensive. During the intensive, we ask participants not to drink any alcohol, watch TV, conduct business as usual—in short, to be totally focused on recovery and the restoration of the relationship. Do you agree to abide by these requirements?

Month you are considering an Intensive:

Any additional comments: