"Restoring Truth" Disclosure Support Group - Safe Haven Mentoring & Coaching, LLC

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Complimentary 30 MINUTE CONSULTATION

Complimentary 30 minute Pre-Coaching Consult view more...

'Restoring Truth' Disclosure Thursday Support Group

4 Group Sessions Thursdays 2:00 pm EDT view more...

$206.10

'Restoring Truth' Disclosure Tuesday Support Group

4 Group Sessions Tuesday @ 12:00pm EDT view more...

$206.10

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Book your COMPLIMENTARY CONSULTATION with LAURA JENKINS now.

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7/3/25

Hello client,

Before we have our consult I would like to ask you a couple of questions to prepare for our conversation. This will allow me to better understand your needs and how I may best be able to coach you and facilitate your path forward.

1. What is your primary reason for reaching out to Safe Haven Mentoring?

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2. If you could change your life in the next 90 days, what would you change?

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3. Where did you hear about Safe Haven Mentoring?

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Thank you for taking the time to answer these questions. I'm looking forward to meeting with you soon.

LAURA

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Thank you for taking the time to complete this form which helps me better coach and understand your situation. Respond to as many of the questions as you can. Reach out to me if you have any issues.

7/3/25

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Your Contact Details:

Phone Number

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Email Address

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Best time to call?

Morning Afternoon Evening{"type":"checkbox","name":"__generic3","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Morning\nAfternoon\nEvening"}

Is it OK to leave a message on your phone?

Yes No{"type":"radio","name":"__generic5","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"Yes\nNo"}

Preferred contact method?

Email Phone Text{"type":"radio","name":"__generic4","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Email\nPhone\nText"}

Personal Information:

Marital Status

Married/Domestic Partner Separated Divorced Widowed{"type":"checkbox","name":"__generic10","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Married/Domestic Partner\nSeparated\nDivorced\nWidowed"}

Children living at home?

Yes No{"type":"radio","name":"__generic15","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}

What are the ages of your children living at home?

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Please answer the following, check which applies:

1. I suspect that my spouse/partner is engaging in sexual behavior outside the bounds of our relationship.

Yes No Don't know{"type":"radio","name":"__generic7","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nDon't know"}

2. I have discovered pornography or sexually explicit material on my spouse/partner's electronic devices.

Yes No Don't know{"type":"checkbox","name":"__generic8","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo \nDon't know"}

3. Has your spouse/partner disclosed to you his acting behavior?

Yes No Don't know{"type":"radio","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes \nNo\nDon't know"}

4. Is your spouse/partner in recovery, e.g. seeing a therapist or attending a 12 Step or men's support group ?

Yes No Don't know{"type":"radio","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes \nNo\nDon't know"}

The following questions relate to what you would like me to know about how you are showing up in life right now?

5. How would you rate your overall health?

Excellent Very Good Good Fair Poor{"type":"radio","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Excellent\nVery Good\nGood\nFair\nPoor"}

6. Do you experience difficulty sleeping?

Yes No Sometimes{"type":"radio","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nSometimes"}

7. Do you have difficulty concentrating and making decisions for yourself?

Yes No Sometimes{"type":"radio","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nSometimes"}

8. Do you experience anxiety?

Yes No Sometimes{"type":"radio","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nSometimes"}

9. Are you currently under the care of a therapist or counselor?

Yes No{"type":"radio","name":"__generic17","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}

10.Have you attended, or are currently participating in a support group for betrayed partners?

Yes No{"type":"radio","name":"__generic18","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}

11. Do you feel safe in your relationship with your spouse/partner?

Yes No Sometimes{"type":"radio","name":"__generic19","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nSometimes"}

12. Has your belief system/faith tradition been a significant factor of comfort or pain in helping you face the situation with your spouse/partner?

Yes No Don't know Doesn't apply{"type":"radio","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nDon't know\nDoesn't apply"}

We're almost there! The next questions concern your support network.

13. Do you have someone you can confide in safely?

Yes No Sometimes{"type":"radio","name":"__generic21","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nSometimes"}

14. Do you have a supportive faith community (faith leader/lay minister)?

Yes No Don't know{"type":"radio","name":"__generic22","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nDon't know"}

15. If you are in the care of a therapist/counselor, are they specialized in treating betrayal trauma?

Yes No Don't know N/A{"type":"radio","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nDon't know\nN/A"}

16. Do you have a plan for taking care of yourself, and your children if they are living at home with you?

Yes No Don't know{"type":"radio","name":"__generic24","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nDon't know"}

17. What is your greatest need right now?

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18. Is there anything you would like to clarify from the questions you have answered in this Intake Form?

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19. Where did you hear about Safe Haven Mentoring?

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Thank you for taking the time to complete this form, it helps me get a better idea of what you are experiencing, and helps me provide the best level of coaching you deserve. I have been where you are today and know what a lonely and painful journey this can be. I'm looking forward to meeting with you soon.

LAURA

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Time Zone:	We think it's . let me choose... Show All

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You will be billed immediately $206.10.

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