Questionnaire EW Bootcamp

Name*

First Last

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

Phone Number*

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

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

2. What made you decide to join the Empowerment Wheel Boot Camp?*

Other:*

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

Engaged
Married
Living Together
In-House Separation
Separated
Going Through Divorce
Divorced
Divorced and Remarried
Single

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

5. Do you have children?*

Yes
No

How old are they?*

6. What City are you in?*

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

8. What Time Zone are you in?*

9. What is your age range?*

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

Yes
No

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

12. Are you currently in or have you regularly attended a betrayal trauma support group?*

Yes
No

What's the name of the group?*

If yes is it:*

Face to Face
Over the Phone
Zoom/Skype

13. Are you currently seeing a counselor?*

Yes
No

Are they CSAT, CPTT or APSAT trained?*

Yes
No
Don't Know

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 meeting you and praying for you in advance by name.

- Dr. Sheri

14. Please Finish This Sentence With 5 Feeling Words. Before Coming To The Empowerment Wheel™ Boot Camp I Feel...*

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

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

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

Yes
No
Not Sure

18. In a few sentences what three issues about the sexual betrayal and acting out concerns you the most?*

19. 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

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

Yes
No

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

Other:*

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

Other:*

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

Yes
No

24. In A Few Sentences, What Are 3 Things You Hope To Gain From Participating in The Empowerment Wheel™ Boot Camp?*

25. In a few sentences, how do you feel most powerless/helpless in your relationship with your spouse/significant other today?*

26. Who in your life do you admire for their self-assurance and strength (can be someone you know, someone in a movie, the media, a book, fictional character, etc.)*

27. I’d like you to think about a challenging situation in your relationship with the sexual betrayer. If you were to imagine yourself with more self-assurance and stronger in your relationship, what qualities or strengths would you need most?*

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

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Getting to Know You Before We Meet