From Harm to Healing – Stage 1 Course Form - Chris Jones Therapy

Skip to content

Chris Jones Therapy

Home
About Me
Services
Course
Podcast
Articles
FAQ
Contact Me
Members

Chris Jones Therapy

Home
About Me
Services
Course
Podcast
Articles
FAQ
Contact Me
Members

From Harm to Healing – Stage 1 Course Form

To apply for the Stage 1 program, please start by completing the following form. You will then be able to schedule the 30-minute consultation call.

Logistics(Required)

I confirm that I have double-checked the group start time in my own time zone and can attend at the scheduled time.

I understand that I am responsible for checking any time-zone or daylight-saving changes and how these may affect the session time in my location.

Personal Details

Your Name(Required)

First Last

Partner's Name (if applicable)

First name only

Date of Birth(Required)

Day

Month

Year

Your Address(Required)

Street Address Address Line 2 City County / State / Region ZIP or Postal Code Country

Your Email Address(Required)

Email Address Confirm Email Address

Current Situation

Are you currently living with your partner(Required)

Yes

No

Other

Do you currently have children or other dependants living with you?(Required)

Yes

No

Other

Have you completed a full therapeutic disclosure?(Required)

Yes

No

Other

Do you currently have a therapist or other professional mental health support?(Required)

Yes

No

Have you previously had a therapist?(Required)

Have you ever been diagnosed with a mental health condition?(Required)

Yes

No

Please provide brief details(Required)

Are there any current or previous legal issues, criminal investigations, convictions or offending behaviours that may be relevant to your participation in the program?(Required)

Yes

No

Please provide brief details(Required)

Experience and Motivation

How long have you been engaged in some form of recovery for deceptive sexuality behaviours?(Required)

How were you first introduced to the Deceptive Sexuality and Trauma (DST) model?(Required)

How have you engaged with the DST model so far (for example, through podcasts, articles, courses or treatment.)(Required)

What is the current status of the sexual behaviours that have caused concern or harm?(Required)

Stopped

Mostly stopped, with occasional lapses

Some behaviours are still ongoing

Significant behaviours are still ongoing

Unsure

Please briefly expand on your answer above. For example, describe any behaviours that are still ongoing, any recent lapses, or anything that helps explain your current situation.(Required)

What has led you to apply for the From Harm to Healing program at this point, and what do you hope to gain from the program?(Required)

What do you currently understand about the impact your sexual behaviour, secrecy and/or deception has had on your partner or others?(Required)

Declaration and Acknowledgement

IMPORTANT(Required)

Yes – I confirm that the information I have provided in this form is accurate and complete to the best of my knowledge.

Yes – I understand that completion of this form and attendance at an assessment consultation does not guarantee a place on the Stage 1 program.

Yes – I understand that From Harm to Healing is a psychoeducational and coaching program and is not a substitute for therapy.

Yes – I understand that participation in Stage 1 requires regular attendance, active engagement, and completion of homework between sessions.

Δ

Copyright © Chris Jones Therapy - All Rights Reserved. Privacy Policy

Copyright © Chris Jones Therapy - All Rights Reserved