Relationship Therapy Application

1
How did you first come in contact with us?* This field is required.
Google
Facebook
Instagram
Referral
Other
2
Please state your referral* This field is required.
3
Which of the following best describes your current relationship status?* This field is required.Please tell us a little bit about yourself, so that we can better understand your situation.
Single
Dating / Long Term Relationship / Engaged
Married
Poly
Other
4
The relationship challenges you face at age 18 aren't the same as those you'll face at 68. To help us understand what you would most benefit from, which of the following best describes your age?* This field is required.
20's
30's
40's
50's
60's
70's or older
5
Tell us about yourself, your situation, and what's making you look for guidance at this time.* This field is required.Please be as detailed and specific as possible.
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6
Thank you! Since we only have a limited number of openings available to work with new clients, tell us what you are looking to achieve as we work together.* This field is required.Please be as detailed and specific as possible. What’s your vision or dream here? How would you define “success”?
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7
As a specialized practice, our openings are limited and we want to make sure that we are a good fit for what you are looking for. Could you say more about why you feel ready for this work now? (Please share why you are confident in your ability to commit in this specialized work at this time)* This field is required.Tell us what makes your readiness for this work unique or apparent.
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8
Working with us usually requires an investment of at least $2,500. Have you made the funds available to make this investment right now?* This field is required.
Yes
No
9
Given the investment described above, how are you hoping to cover the cost of working with us?* This field is required.
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10
Not finished yet...the last (and most important) step: please confirm your contact information below and then schedule a time for a phone consultation with our Intake Scheduler to get you connected with the right clinician.* This field is required.STEP 1: Submit your contact information below. STEP 2: On the next page, pick a time that works with your schedule. STEP 3: You'll receive an email immediately from Acuity with your scheduled time. We will be calling you on that date/time, so mark your calendar.
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