* 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?

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

* 3. Best phone number to reach you?

* 4. What is your preferred time to meet with a counselor? (Our clinic is open M-F 9-5 and Tues, Wed, Thur evenings 5-8)

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

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