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Couples Clinic

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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?

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

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* 3. Best phone number to reach you?

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* 4. 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)

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* 5. 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. 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)

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* 7. 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?

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* 8. We are offering telehealth/ videoconferencing couple therapy for those that need it during this time of Coronavirus

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

It would be helpful for me/us, it's really hard for us to get to the office meetings weekly or we need to quarantine

It's a great idea. This would be helpful for most any couple.

No preference, we are flexible

Any other thoughts about telehealth?

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* 9. 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

A healthy relationship check: Assessment and feedback for personal growth (free)

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

Other (please specify)

READ ME

Thank you for your responses. We have a collection of questions about various aspects of your relationship that we ask couples to complete prior to beginning. This takes 20 minutes for most people. It is best if you are willing to complete it online. However there are reasons why some people prefer to complete the questions on paper and you can request that by phone or email. BOTH partners will have to complete the questions to begin couple counseling or the Healthy Relationship Check with one of our counselors.

After one of you completes the questionnaires you will be taken to an online scheduler to pick an initial screening appointment. The initial screening appointment is free. (Regular therapy sessions are $40, regular price). If this is a financial barrier to seeking treatment for you please discuss this with the counselor in your first meeting as there are options for reduced cost. The Healthy Relationship Check & feedback is free.

If you have questions you want to ask prior to scheduling, please contact us by email hopecouples@hopecouples.com or call 757-352-4896.

PLEASE NOTE: If you do not schedule an initial screening on the 10to8 calendar we will assume you decided not to begin this process now. You will have to go complete the registration page again.