APPLICATION for COUPLES THERAPY DOCUMENTARY
If you're looking for couples therapy, and are open to sharing your story, we'd love to hear from you!
First Name *
Your answer
Last name
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Partner's Name
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Your Email *
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Your Age
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Partner's Age
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How long have you been together? *
Your answer
Why do you want couples therapy? *
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Sexual Orientation *
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Ethnicity
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Do you have children? *
If yes, list age(s)
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City & State of Residence *
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Phone Number
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How did you find us? Please be as specific as possible. *
Your answer
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