Exit Summer/Fall 2023 Couples Clinic at RU Question Title * 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? Question Title * 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. Question Title * 3. I give permission for the staff of the Hope project to email me at this email address. Yes Question Title * 4. Best phone number to reach you? Question Title * 5. What is your partner's name? Question Title * 6. In general, what days/times would the two of you be able to meet? Monday Tuesday Wednesday Thursday Friday morning (9-11) morning (9-11) Monday morning (9-11) Tuesday morning (9-11) Wednesday morning (9-11) Thursday morning (9-11) Friday lunchtime (11-2) lunchtime (11-2) Monday lunchtime (11-2) Tuesday lunchtime (11-2) Wednesday lunchtime (11-2) Thursday lunchtime (11-2) Friday afternoon (2-5) afternoon (2-5) Monday afternoon (2-5) Tuesday afternoon (2-5) Wednesday afternoon (2-5) Thursday afternoon (2-5) Friday evening (5-8) evening (5-8) Monday evening (5-8) Tuesday evening (5-8) Wednesday evening (5-8) Thursday evening (5-8) Friday Other (please comment) Question Title * 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? Question Title * 8. What is the type of relationship you are in? Dating, not living together or engaged Living together, not engaged Engaged, not living together Engaged, living together Married Separated Question Title * 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) Question Title * 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) Question Title * 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? Question Title * 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? Question Title * 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) Question Title * 14. Your Age Question Title * 15. Your race/ ethnicity Question Title * 16. Sexual orientation/ gender identity Question Title * 17. Religion READ METhank 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. Done