First Name *

Last Name

Partner Name

Email *

Phone *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (719)522-1073 for assistance. You can reply STOP to unsubscribe at any time.

Preferred Language *

English

Spanish

Service

Couples Clinic

Individual Intensive

Media Request / Speaking Invitation

CLERA

General Inquiry

Are you married *

Yes

Why are you seeking help today? *

Sex

Loneliness

Infidelity

Time apart

Irritating habits or behaviors

Unmet expectations

Friends, family, or other non-marital relationships

Household responsibilities

Children and parenting

Financial problems

Please select all that apply

How long has this been going on?

In your own words, how is this issue affecting your relationship?

Are you currently seeing a therapist?

Yes

Are both partners in agreement to receive professional support?

Yes

Are you both willing and able to travel?

Yes

Maybe

Speaker *

Jorge

Danisa

Please select all that apply. If you would like Jorge AND Danisa, please select both names.

Dates Requested *

Alternative Dates

Open to Jorge/Danisa's availability

Please provide alternate dates in "Other" field if available.

Audience Type *

General

Women

Men

Leaders

Youth

Invitation Type *

Interview / Media

In-Person Engagement

I am prepared to provide an honorarium. *

Yes

Event Type *

Conference

Weekend Service

Mid-Week Service

Conference & Weekend Services

Church / Organization Name *

Event Address

Estimated Attendance *

Total conference or service attendance. For weekend/multiple services, please provide combined estimate.

Recording Type *

Interview (podcast, IG live, YouTube, etc.)

Virtual Message

Greeting / Promo

Media Format *

Podcast

Social Media

Radio

Program Name

Interviewer Name *

The interview will be *

Live

Pre-recorded

Interview Length

Please provide your answer in minutes.

Release/Broadcast Date

If same as requested date(s), please leave blank.

Referrer

Speaking Event

Social Media

YouVersion

Enlace

Referral

Why Us?

Additional Information

You're almost done! Hit the SUBMIT button to complete.

¡Ya casi terminas! Presione el botón SUBMIT para completar.