PREP Course Registration Form

Healthy Relationships for Couples Registration Form

Welcome and thanks for your interest in the PREP Healthy Relationships 10-Week Course. Couples of all races, genders, spiritual backgrounds, socio-economic status, and age 18+ are welcome to apply. Each person should complete this form individually and will be scheduled for a 30 minute 1-on-1 interview to confirm course eligibility.
Your Name

First NameMiddle NameLast Name
Name of Partner

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
E-mail
example@example.com
Best Contact Number

Area CodePhone Number
Have you been in a relationship with your partner for at least 1 year?

YesNo
Are you and your partner willing to attending all weekly sessions together?

YesNoUnsure
Check each line indicating you read and understand each point:

Classes are on Thursdays from 6:00 p.m. to 7:30 p.m.Class is attended in person (there is no Zoom option)I want to do this of my own free willMy partner wants to do this of their own free willWe do not have a history of domestic violence in our relationship with each otherThis is an educational class, not group therapy, not a support groupI will commit to completing in-class activities and homework to the best of my ability
Which lesson topics interests you most? (Check all that apply)

3 Keys to SuccessFun & FriendshipDangers Signs & Time OutSpeaker / Listener TechniqueAnger & StressExpectationsPersonalityEvents & IssuesHidden IssuesCommittment
Questions or something you want us to know?
Should be Empty:

Healthy Relationships for Couples Registration Form