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Recovery of Self

COUNSELING & INTENSIVES

Kate Parkinson
LMFT, CSAT, CEMDR, CHFP

Providing Virtual Psychotherapy Sessions and Intensives

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INTENSIVE APPLICATION

Recovery of Self Counseling Application for Three-Day Intensive

Recovery of Self Counseling
Application for Intensive

Welcome to Recovery of Self Counseling. In order to be considered for an Intensive, please answer all the questions below and, when finished, click on the "Submit" button. You will be contacted soon regarding your application.

Each person must fill out his/her own application. DO NOT fill out an application for your spouse/partner. By completing this application you are attesting that you are the person named below.

Name

Email

Date of Birth

Phone Number

Mailing Address

City

State

Zip Code

Country

How did you learn about the Recovery of Self Counseling Intensive program?

What type of Intensive(s) are you interested in? Please check all that apply.

Couple's Intensive

Individual Addict

Individual Partner

Individual Trauma Care

Marital Status

Partners Name

Partner's Date of Birth

How long have you been in your current relationship?

Do you have any children?

Yes

No

If yes, please give first names and ages.

Your Occupation

How would you describe your current work situation?

Partner's Occupation

How would you describe your partner's current work situation?

Are you currently seeing a therapist?

Yes

No

If Yes, please give name of therapist.

Name of previous therapist(s), if any.

Please indicate which addictions you currently have or have struggled with in the past.
Sex, porn and/or love

Not Yet in Recovery

Currently in Recovery

Not Applicable

Alcohol and/or other drugs

Not Yet in Recovery

Currently in Recovery

Not Applicable

Intimacy avoidance

Not Yet in Recovery

Currently in Recovery

Not Applicable

Work

Not Yet in Recovery

Currently in Recovery

Not Applicable

Co-dependency

Not Yet in Recovery

Currently in Recovery

Not Applicable

Compulsive shopping/compulsive spending

Not Yet in Recovery

Currently in Recovery

Not Applicable

Food or Eating Disorder

Not Yet in Recovery

Currently in Recovery

Not Applicable

Other internet related compulsive behavior

Not Yet in Recovery

Currently in Recovery

Not Applicable

Other Addictions

Not Yet in Recovery

Currently in Recovery

Not Applicable

Do you currently attend 12-Step meetings?

Yes

No

If yes, which program(s)?

How many meetings do you attend in a typical week?

Have you ever attempted to take your life?

Yes

No

If yes, please give complete details about that event. If you have made more than one attempt on your life,
give details on each incident.

When was the last time you thought about taking your life?

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?

Yes

No

Commitment to Marriage: One of the major goals of Recovery of Self Counseling Intensives is to see
marriages/relationships healed and restored. Our Intensives are designed to help move couples toward a
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 a commitment to remain in the marriage/relationship
after the Intensive. For the partner, we require that commitment of at least 12 months after the Intensive.
For the sex addict, we require a commitment of at least 24 months after the Intensive. Do you agree to
abide by this requirement?

Yes

No

In Preparation for an Intensive: We ask that participants not drink any alcohol or use any other substance
of abuse including marijuana for at least 30 days prior to the Intensive or during the Intensive. Do you agree
to abide by these requirements?

Yes

No

During the Intensive: It is important that you refrain from checking your email, text messages or social media,
surfing the internet and playing games on any digital devices or conduct business as usual. In short, we
need you to be focused on recovery and the restoration of the relationship. Do you agree to abide by
requirements?

Yes

No

During what month you would like to participate in an Intensive?

Regarding the concern that brought you to Recovery of Self Counseling, please rate the significance of this
problem or concern in your life: ("1" meaning "Very Minor" to "10" meaning the "Greatest Problem in my Life").

1

2

3

4

5

6

7

8

9

10

Please indicate how willing you are to do what is necessary to alleviate this problem or concern:
("1" meaning "Not Willing to Change Anything" to "10" meaning "I'll do Whatever It Takes").

1

2

3

4

5

6

7

8

9

10

Any additional comments you would like to make?

Thank you for completing my Recovery of Self Counseling Application for Intensive form.

I will contact you shortly.

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