Thank you for your interest in the Couples Clinic at Regent University.  If you are interested in the Couples Clinic, please answer the following questions.  
We occasionally send e-mail updates on services provided or upcoming workshops but only a few times a year and we never sell your information to others.

What is your name?

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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 answer the following questions.  
We occasionally send e-mail updates on services provided or upcoming workshops but only a few times a year and we never sell your information to others.

What is your name?

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

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

Best phone number to reach you?

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* 3. Best phone number to reach you?

What is your preferred time to meet with a counselor? Our clinic is open summer of 2018 on
Tuesdays 11-8; Thurdays 3-8; Fridays 10-5.  
We hope you can find a time to meet during our open hours!

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* 4. What is your preferred time to meet with a counselor? Our clinic is open summer of 2018 on
Tuesdays 11-8; Thurdays 3-8; Fridays 10-5.  
We hope you can find a time to meet during our open hours!

What additional times could you meet with a counselor if your preferred time spot was full?

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* 5. What additional times could you meet with a counselor if your preferred time spot was full?

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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* 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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