Name: ___________________________________________ Date: ________________________

We exist to help men who struggle with sexual brokenness find recovery through Jesus and his
Holy Spirit and grow in healthy relationship with God our Father.

We have learned that we must – Embrace our brokenness; Confess our struggles to one another;
Pray for and support one another without judgment.

We believe that true and lasting healing comes from God. We know that He loves us and desires for us to live in
sexual purity. Anyone who is willing can come to Him and find healing and a breaking free from sexual sin and brokeness.
We also believe that to maintain that freedom we must experience transformation by the filling of the Spirit and walking in
the Spirit.

God has done his part and has given us everything we need for life and godliness. (2 Peter 1:3) Yet, we still must
learn to deal with …
● Our sin nature (our flesh) that dwells within us.
● Our sexualized world in which we live
● The spiritual forces of evil that are arrayed against us.

In the context of a Christian Community. Participants are encouraged to confront their brokenness and the issues
underlying it in an environment of care and accountability without condemnation. Bringing what has been hidden into the
light opens the door for God to begin the healing process.

This ministry began in 2009 with the expressed purpose of providing a support and recovery group that emphasizes not
only the healing power of God but also, the personal responsibility of men to do whatever it takes to live a life of purity.

This is not a group for those looking to occasionally attend and go home! The ones breaking free from their sexual
brokenness and experiencing the life God has for them are those who:
● Make being here a priority!
● Participate in the teachings!
● Openly share in the small groups to confess sins and receive prayer for their struggles!
● Do the assigned work during the week!

We do not believe one can participate for three to six months and then their problems will be solved. Some of us have
been developing our sexual brokeness for decades. We understand that we are working on dramatically changing our
mindsets, values, thought patterns, habits, and lifestyle and are becoming the new creations God has designed us to be.
This will take the rest of our lives, but it is accomplished one step at a time. We know that it is worth it, and it gets better
the longer we continue to work in deepening our relationship with God and one another.

You are welcome to attend and observe to see if 180 is for you. If you are not yet ready to make that commitment, we
understand it takes time and you are always welcome here. However, if you have reached the point where you are sick
of your sexual sin and failures and are willing to do whatever it takes to be free to experience the life God wants you to
have then we welcome you to participate in the program with us.

180 is a ministry lead by volunteers who are also recovering from sexual brokeness. The leaders will come alongside you
in your journey, but they are unable to offer professional or legal advice. Participants are encouraged to seek a variety of
resources and support in addition to 180 including pastoral, mental health, legal, and medical services as appropriate.
180 Ministries Intake Packet – 180Recover.com Page 2

Application
This application contains questions that will be difficult for you to answer. We will maintain a high level of confidentiality.
Only the 180 Director and your small group leader will read this and then it will be returned to you. This information will
help us assign you to the appropriate small group leader and evaluate where you are in the healing process. You do not
have to tell us everything but what you do share will help us place you in the best small group for you.

Please fill in this application with as much detail as you can. Feel free to use the back of the page if necessary. Your
responses will be kept strictly confidential.

Email: ____________________________________ Phone: ______________________ Age: ______ Date: _________

I am currently (circle one): SINGLE MARRIED SEPARATED DIVORCED WIDOWED

1. Please share with us briefly your reasons for attending 180.

2. For how many years have you struggled with sexual sin? ____________

3. Would you consider yourself a sexual addict? YES NO Not Sure

4. What areas are you struggling with or have struggled with in the past? (Check all that apply)

Masturbation Indecent Liberties Phone Sex /

Exhibitionism (i.e. illegal sexual Cybersex
conduct) Bestiality
Sadomasochism
Massage parlors Incest
Voyeurism
Prostitution Anonymous
Rape
Pedophelia encounters
Extramarital affairs
Fantasy Molestation

5. Is your sexual struggle with (circle one): Opposite Sex Same Sex Both

6. Do you recall any significant traumatic incidents in your life? (for example: verbal physical, sexual, or emotional
abuse)? If so, please describe:

7. How does your struggle express itself sexually (pornography, masturbation, fantasy, same sex attraction, affairs,
etc.)?

8. Do you have any non-sexual problem behaviors or addictions (i.e. overeating, alcohol/chemical dependencies,
emotional dependency, spending, gambling, workaholic, etc.)?

9. Who in your life knows about your truffles and is supportive in your healing? (Friends, Wife, Pastor, Counselor,
Small Group Leader)

180 is a ministry of Vineyard Columbus – email: info@180Recover.com

180 Ministries Intake Packet – 180Recover.com Page 3

10. Are you currently receiving ongoing pastoral or professional counseling? YES NO
If so, for how long?

11. Are you currently receiving help from another healing ministry or support group? YES NO
If so, please list the group, ministry, etc.

12. Do you know you have a relationship with Jesus Christ and have accepted him as your personal savior?
YES NO NOT SURE

13. Are you currently participating in ongoing fellowship within a church? YES NO
If so, which church fellowship do you attend?

14. Have you ever been diagnosed with depression or contemplated suicide? YES NO
If so, please explain

15. Are you currently entertaining thoughts of suicide? YES NO

If so, please explain

16. Do you abuse alcohol or other mood-altering substances? YES NO

If so, please explain

17. Do either of your parents struggle with alcohol, drugs, or any sexual addictive behaviors? YES NO
If so, please explain

18. Do you struggle with any same sex attractions, fantasies or feelings? YES NO
If so, at what age did you experience this?

19. At what age did you experience your first sexual encounter:

OPPOSITE SEX YES NO AGE _____

SAME SEX YES NO AGE _____

20. Are you currently involved in sexual conduct with someone? (if married, other than your wife?) YES NO
If so, please explain:

21. Have you ever been involved in sexual conduct, outside of marriage, with someone other than your spouse (male
or female)? YES NO

If so, for how long did that occur?

22. Have you ever attended this group or a similar recovery group before? YES NO
If so, when?

Please take the test on the next page, sign the Confidentiality Policy and return this application to the 180 Director at your
next meeting.

180 is a ministry of Vineyard Columbus – email: info@180Recover.com

180 Ministries Intake Packet – 180Recover.com Page 4

Sexual Addiction Screening Test 1

Instructions: Place a checkmark in the “YES” or “NO” column for each of the following screening questions.

Screening Question YES NO

1. Were you sexually abused as a child or adolescent?
2. Did your parents have trouble with sexual behavior?
3. Do you often find yourself preoccupied with sexual thoughts?
4. Do you feel that your sexual behavior is not normal?
5. Do you ever feel bad about your sexual behavior?
6. Has your sexual behavior ever created problems for you and your family?
7. Have you ever sought help for sexual behavior you did not like?
8. Has anyone been hurt emotionally because of your sexual behavior?
9. Are any of your sexual activities against the law?
10. Have you made efforts to quit a type of sexual activity and failed?
11. Do you hide some of your sexual behaviors from others?
12. Have you attempted to stop some parts of your sexual activity?
13. Have you felt degraded by your sexual behaviors?
14. When you have sex, do you feel depressed afterwards?
15. Do you feel controlled by your sexual desire?
16. Have important parts of your life (such as job, family, friends, leisure activities) been neglected
because you were spending too much time on sex?
17. Do you ever think your sexual desire is stronger than you are?
18. Is sex almost all you think about?
19. Has sex (or romantic fantasies) been a way for you to escape your problems?
20. Has sex become the most important thing in your life?
21. Are you in crisis over sexual matters?
22. The internet has created sexual problems for me.
23. I spend too much time online for sexual purposes.
24. I have purchased services online for erotic purposes (sites for dating)
25. I have used the internet to make romantic or erotic connections with people online.
26. People in my life have been upset about my sexual activities online.
27. I have attempted to stop my online sexual behaviors.

1
Source: © 2008, P. J. Carnes, Sexual Addiction Screen Test - Revised

180 is a ministry of Vineyard Columbus – email: info@180Recover.com

180 Ministries Intake Packet – 180Recover.com Page 5

Screening Question YES NO

28. I have subscribed to or regularly purchased or rented sexually explicit materials (magazines,
videos, books or online pornography).
29. I have been sexual with minors.
30. I have spent considerable time and money on strip clubs, adult bookstores and movie houses.
31. I have engaged prostitutes and escorts to satisfy my sexual needs.
32. I have spent considerable time surfing pornography online.
33. I have used magazines, videos or online pornography even when there was considerable risk of
being caught by family members who would be upset by my behavior.
34. I have regularly purchased romantic novels or sexually explicit magazines.
35. I have stayed in romantic relationships after they became emotionally abusive.
36. I have traded sex for money or gifts.
37. I have maintained multiple romantic or sexual relationships at the same time.
38. After sexually acting out, I sometimes refrain from all sex for a significant period.
39. I have regularly engaged in sadomasochistic behavior.
40. I visit sexual bath-houses, sex clubs or video/bookstores as part of my regular sexual activity.
41. I have engaged in unsafe or “risky” sex even though I knew it could cause me harm.
42. I have cruised public restrooms, rest areas or parks looking for sex with strangers.
43. I believe casual or anonymous sex has kept me from having more long-term intimate relationships.
44. My sexual behavior has put me at risk for arrest for lewd conduct or public indecency.
45. I have been paid for sex.

Total the number of “YES” answers – enter the number here: ___________________

LASTLY, PLEASE READ AND SIGN THE CONFIDENTIALITY POLICY ON THE NEXT PAGE.

THE SIGNED CONFIDENTIALITY POLICY PAGE IS THE ONLY PART OF THIS APPLICATION THAT WILL
NOT BE RETURNED TO YOU. THESE ARE KEPT ON FILE IN A SECURE LOCATION.

180 IS A SAFE PLACE FOR MEN WHO ARE HONEST ABOUT THEIR PROBLEMS AND ACTIVELY
WORKING THEIR RECOVERY PROCESS.

CONFIDENTIALITY IS EXTREMELY IMPORTANT TO US AND FOR ALL WHO ATTEND.

180 is a ministry of Vineyard Columbus – email: info@180Recover.com

180 Ministries Intake Packet – 180Recover.com Page 6

Confidentiality Policy for 180 Ministries

180 Leadership will hold as confidential all disclosures made in the context of the Small Group with these four
exceptions:

1. All group leaders reserve the right to discuss matters disclosed by group members for the purpose of
receiving supervision and oversight. This oversight will occur in group supervision meetings held by the
group leader and attended by other group leaders on a weekly basis. This is done anonymously.

2. Any group member who discloses intentions to take harmful, dangerous, or criminal action against
another human being or against themselves will necessitate us to warn the appropriate individuals of
such intentions and report it to the authorities. Suspected acts of child abuse or neglect will be
reported. Those warned may include a variety of such persons as:

a. The person or family of the person who is likely to suffer the results of harmful behavior.
b. The family of the group member who intends to harm himself or someone else.
c. Associates or friends of those threatened or making threats
d. Appropriate authorities including but not limited to law enforcement officials, and/or child
protection services.
e. If you disclose that you are using child pornography or are abusing anyone under the age of 18,
we are a mandated reporter and must report this to the proper authorities.

3. 180 is a ministry of Vineyard Columbus

4. If you do not regularly attend Vineyard Columbus, we reserve the right to disclose confidential
information to your pastor, counselor, and/or other leadership of the church you presently attend.

I have read, understand and agree to this confidentiality policy, including its exceptions.

Name (Please Print) _________________________________________________

Signature ______________________________________ Date _____________________

180 is a ministry of Vineyard Columbus – email: info@180Recover.com