Couples Therapy Wait List Registration

*You will get a confirmation email coming from the following email address: Tina@Betteryourself365.com. Please make sure to whitelist this email if it went to your junk mail, or add it to your contact list to ensure you get all of my emails.*

Divider

HTML

Partner One Information

First Name *

Last Name *

Email *

Phone *

Divider

HTML

Partner Two Information

First Name *

Last Name *

Email *

Phone *

Divider

Name of your medical insurance plan if applicable

How did you hear about my services? *

Which program will you likely want? This will be officially determined after our consult call. *

Basic Program
Advanced Program

Did you want me to add your emails to my newsletter for couples? You will receive a weekly email on how to Better your Health and Better your Relationships. You can unsubscribe at any time. *

Yes
No

Specify any additional information you feel is needed at this point

Recaptcha

QUICK CONTACT

Fields marked with an * are required.

First Name *

Last Name *

Phone *

Email *

What would like to a consult about? *

Comments