Gateway Application (Be Broken Ministries)

Gateway Application

Please fill out the application below to complete Step 1 in the registration process. Once you have completed the application please submit your registration payment online or call us toll free at 1.800.49.PURITY M-F 9-3 CST.

Your application will take no longer than 1 business day to process. When your application is approved and your payment is processed, you will then receive a confirmation packet by mail prior to the event date that contains all the information you need to prepare for the upcoming workshop.

(ALL answers are confidential)

Workshop Attending (select one) *

Name (First & Last) *

Preferred Name (i.e., John, JD, etc.)

Mailing Address *

City *

State *

E-mail Address: *

Zip *

Home Phone *

Work Phone

Cell Phone

Primary Struggle *

Eligibility (check all that apply) *
I struggle with sexually addictive thoughts & behaviors I am over 18 years old I desire help for my addictive patterns
Addiction Survey (check all that apply) *
I have engaged in sexual behaviors that I wish I could stop. I feel abnormally driven by my sexual drive. I have been in a relationship just for sex. Masturbation has been ongoing even after marriage. I have continued to use pornography after entering a long-term committed relationship. My sexuality seems to be dragging down my personal potential. I spend a significant amount of time viewing porn or grooming others for sexual encounters. I have experienced unwanted sexual encounters during childhood or adolescence. Monogamous sex has grown to be boring.
Workshop Attendance Requirements (check to agree) *
I understand GTF is a Christian, Bible-based workshop. I understand and agree to shared lodging while attending the workshop.
Roommate Request

Where did you hear about Gateway to Freedom?



* Required

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