Small Group Questionnaire

Name*

First Last

Email (Please use the one you joined the B1C with)*

Phone Number*

1. How Did You First Hear About The BraveOne Community?*

Other:

2. What made you decide to join a B1C Coaching Group?*

3. What's your relationship status? Check all that apply.*

4. How long have you been married or in the relationship?*

5. Please enter a name for your Emergency Contact*

First Last

6. Please enter your Emergency Contact Phone Number*

7. What is your age range?*

8. Do you have children?*

Yes
No

If yes, how old are they?*

9. What City are you in?*

10. What State and/or Country are you in?*

11. What Time Zone are you in?*

Pacific Time
Mountain Time
Central Time
Eastern Time
Other - Fill in Below

Timezone*

12. The Team and I will do our best to accommodate your schedule. However, our greatest priority is to connect you with others that share similar struggles and stages in their relationship. So we ask that you remain very flexible in your availability. Please let us know what your availability is below. All times are shown in Pacific Time. CHECK ALL THAT APPLY.*

Mondays: 11am - 12:30pm PT
Mondays: 2pm - 3:30pm PT
Mondays: 4:30pm - 6pm PT
Tuesdays: 2pm - 3:30pm PT
Thursdays: 1pm - 2:30pm PT
Thursdays: 4pm - 5:30pm PT Separated/Divorcing/Divorced

Anything about your availability you'd like to add?

13. Have you had the opportunity to read my book Intimate Deception: Healing the Wounds of Sexual Betrayal?*

Yes
No

14. How would you describe your spiritual life? Do you have a particular faith orientation?*

15. Excluding a B1C Small Group, are you currently in or have you regularly attended a betrayal trauma support group?*

Yes
No

If yes is it:*

Face to Face
Over the Phone
Zoom/Skype

What's the name of the group?*

16. Are you currently seeing a coach, counselor, or therapist?*

Yes
No

Are they CSAT, CPTT or APSAT trained?*

Yes
No
Don't Know

17. Do You Know Someone Else Who's Joining a BraveOne Community Small Group? Or would you like to request a specific BraveOne Coach?*

Yes
No

If So Please Type In Their Name(s).

First Last

While I Can't Make Any Promises, Mark This Box If You'd Like Us To Try And Put You In The Same Group.*

Yes, I'd like you to try and put me in the same group as one or more of the people I listed above. This includes a coach I may have listed.
No, I prefer not to be in a group with anyone I listed. (Your answer will remain confidential).
I didn't list anyone.

These next set of questions are more personal. They're really about you and your story. Even writing it down might cause you to have some feelings about where you're at right now. I get it. Be kind, take your time and breathe, knowing that help is around the corner. Your answers will help me have a better idea of what you've been dealing with. I'm looking forward to having you meet your amazing coach and small group.

- Dr. Sheri

18. Please Finish This Sentence With 5 Feeling Words. Before joining a BraveOne Community Small Group I Feel...*

19. How long have you been aware of your spouse/significant other's sexual acting out?*

20. What types of sexual acting out are you aware of? Check all that apply.*

21. Is your spouse/significant other acting out currently?*

Yes
No
Not Sure

22. In a few sentences, what are three issues about the sexual betrayal and acting that concerns you the most?*

23. Does your significant other engage in any of the following depictions of violence on an ongoing basis? Please check all that apply.*

Physical Abuse
Violence (breaking things, throwing things)
Threats of Physical Abuse or Violence
Cruelty to Animals
None of the Above

24. Have you ever had to go to a domestic violence shelter or leave your home because of violence?*

Yes
No

25. Have you been able to receive any type of care for your betrayal trauma? Check all that apply.*

Other:*

26. Has the one who betrayed you received any kind of intervention, treatment, or care? If so, what type? Check all that apply.*

Other:

27. Are you the spouse of a clergy/pastor/priest/rabbi/missionary/serving in ministry that has/is acting out?*

Yes
No

28. In A Few Sentences, What Are 3 Things You Hope To Gain From Participating in a BraveOne Community Small Group?*

29. What would you like me to personally know about your story?*

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B1C Coaching Questionnaire