Summer/Fall 2023 Couples Clinic at RU Survey

1.Thank you for your interest in the Couples Clinic. If you are interested in the Couples Clinic, please answer the following questions.

What is your name?

2.What is your e-mail address? (give a personal email, not a work-email for additional security). Providing us with your email indicates that you consent to communication about scheduling meetings through email. It is not wise or ethical to discuss personal details or therapy content through email.

3.I give permission for the staff of the Hope project to email me at this email address.(Required.)

Yes

4.Best phone number to reach you?

5.What is your partner's name?

7.Are there any restrictions we should know about contacting you? For instance is it OK to leave voicemail messages, call or email at any time?

8.What is the type of relationship you are in?

9.If you have ONE main issue that you would like to address in couple counseling, what would that be? (you can also leave this blank if you prefer)

10.Check if any of the following apply to you as a couple

Problems with chronic pain or chronic illness

Problems with substance abuse (alcohol, marijuana, legal or illegal substances)

Low-income, financial strains

Aggression, physical use of aggression we need to work on stopping

Infidelity, with sexual activity with others we should likely address

Infidelity, with romantic interest in others we should likely address

We are currently separated, living apart and looking to reconcile

Other (please specify)

11.Where did you hear about us?

A friend told me about it

Saw a flyer in the community

The Hope project website

Facebook/ social media

A professional (therapist, doctor, pastor) told me about it

If a professional told you, then who?

12.Are you seeking in-person couple therapy or telehealth meetings?

We prefer in-person meetings, would only do telehealth if required

Prefer telehealth meetings, but available for in person on occasion (live in driving distance to Va Beach)

We live in Virginia but outside of Hampton Roads and would need telehealth (Note we can only provide care for people residing in Virginia due to licensure laws. If you need a referral for another state see https://gottmanreferralnetwork.com/ or https://members.iceeft.com/therapist-search/find-an-eft-therapist.php)

Any other thoughts about telehealth?

13.What kind of couple intervention do you expect to need? (check all that apply)

Standard couple counseling for relationship repair

Pre-marital counseling to prepare for a future together

"Urgent-care" for an affair, separation or similar situation

Relationship education and enrichment (happy relationship looking to maintain health)

Other (please specify)

14.Your Age

15.Your race/ ethnicity

16.Sexual orientation/ gender identity

17.Religion

READ ME

Thank you for your responses. You should hear from us within 3 workdays with options for a meeting with someone in the Hope Focused Couple Counseling network.