Schedule Your Couples Consultation Today!

1
How did you first come in contact with us?* This field is required.
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Referral
PsychologyToday
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ComPsych EAP
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2
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
3
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 and older
4
Can you tell me about yourself, 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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5
Thank you! Since we only have a limited number of spots available to work with new couples, what are you looking to achieve as we work together?* This field is required.Again, please be as detailed and specific as possible. What’s your vision or dream here? What would you define “success” as?
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6
And as I mentioned, spots are limited, only because there's only so much space available in the schedule. Why should we consider accepting you for one of those spots?* This field is required.Tell us what makes your readiness for this work unique or apparent...
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7
Working with us usually requires an investment of at least $2,000. Have you made the funds available to make this investment right now?* This field is required.
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8
Are you intending to use your insurance benefit?* This field is required.(In or out of network? What insurance do you have? What is your insurance ID number and date of birth?)
9
Not Finished Yet... Last (And Most Important) Step! Please Confirm Your Contact Information Below, And Then Select A Time For A Consultation Call On Our Calendar* This field is required.STEP 1: Submit contact information below STEP 2: On the next page, PICK OUT A TIME that works with your schedule. STEP 3: We'll contact you almost immediately to confirm your time, and provide you with a Zoom link to your confidential consultation room (held by video).
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