Summer Couples Clinic Registration

* 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 generally open Tues. - 11:00 am to 8:00pm; Thurs. - 3:00 pm to 8:00pm; Fri. - 9:30 am to 5:00pm)

* 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?

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