Your Email Address  * 
Last Name1
First Name1
Spouse/Significant other/Fiance information
First Name2
Last Name2 (if different from Last Name1)
Email2  * 
In order to provide you with an assessment that addresses your unique aspects of your relationship, what are your spiritual beliefs?  * 
Marital Status:  * 
The cost of the assessment includes: Assessment, workbook, detailed couples report, sessions with a trained facilitator, and a couple check up for later use.
Do you attend Countryside Church?  * 
Total $
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