General 3 — Dating Right

Counselors Form

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

Please state the name of your personal website (if any).

http://

Church Affiliation

Please state the name and location of your regular place of worship

Are you a certified marriage or relationship counselor?

Yes

Are you a full-time or or part-time counselor?

Full-time

Part-time

Do you provide marriage counseling services at your local place of worship?

Yes

Do you host in person counseling sessions?

Yes

Is there any additional information you would like to provide to us about the kind of counseling services you offer?

Counselors

Are you a Christian based marriage or relationship counselor? Would you like to join our host of counselors and reach millions with your services?

Please sign up using the link below and a member of our team would reach out to you.