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* 1. Thank you for your interest in the Couples Clinic at Regent University.  If you are interested in the Couples Clinic please register here.

After you register- you will be taken to a longer questionnaire.  If you are able to complete that questionnaire now, you will then be taken to an online scheduler to schedule your first appointment.  If you need to complete the questionnaire later, that's OK.   Go ahead and register now.

What is your name?

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* 2. What is your spouse/ partner's name?

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* 3. What is your e-mail address? (give a personal email, not a work-email for additional security)

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* 4. Best phone number to reach you?

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* 5. In general, what days/times would the two of you be able to meet?

  Monday Tuesday Wednesday Thursday Friday
morning (9-11)
lunchtime (11-2)
afternoon (2-5)
evening (5-8)

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* 6. Are there any restrictions we should know about contacting you? For instance is it OK to call, text, email at any time?

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