Your first name:

Your partner's first name:

Your last name:

Your partner's last name:

Mailing address:

Mailing address if different:

Phone (work):  

Phone (home):

Phone (work):  

Phone (home):

Cellphone:      

Cellphone:      

E-mail:            

E-mail:            

Current therapist (if any)

Current therapist (if any)

Number of marriages:                     Age:

Number of marriages:                    Age:

Occupation:   

Occupation:  

Employer:       

Employer:       

How did we hear about Rod?

Relationship status:     

 Most of my openings for appointments are on Tuesday or Thursday between 11 and 3 but I also do initial consults on some Friday afternoons.  Please leave two or three ideal times that will work for you and I will do my best to work you in.