Exit

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.

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)
lunchtime (11-2)
afternoon (2-5)
evening (5-8)

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?

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

Question Title

* 11. Where did you hear about us?

Question Title

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

Question Title

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

Question Title

* 14. Your Age

Question Title

* 15. Your race/ ethnicity

Question Title

* 16. Sexual orientation/ gender identity

Question Title

* 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.

T