Participant InformationFull Name(Required)Participant Age(Required)Email(Required) Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status(Required) Yes NoHow Long Have you Been Married?Do you have children?(Required) Yes NoHow many & what are their ages?QuestionsHave you made full disclosure to your wife of all of your sexual history, including the most recent time you acted out?Please describe the current status of your relationship with your wife:Please describe the current state of your sexual relationship with your spouse.Please describe your efforts to date in searching for recovery (groups, counseling, etc):Name 3 things you would like your wife to be able to provide/do for you that would be a big blessing to you:What do you see as your wife’s greatest need for healing?Describe your family of origin:Are you on any medication? If so please list the prescriptions and diagnosis.Are you having any suicidal thoughts?Have you had any exposure to or been involved with occult activities?Have you ever been molested or abused?What is your relationship with the Lord like?When is the last time you had at least one hour of silence with the Lord, alone?What would you say is your greatest need and/or how we could help you the most?CAPTCHADigital Consent(Required) I agree to the privacy policy.Δ
