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Intensive Couples Therapy with Dr. Dome - Application Form

Because not all applicants are good candidates for this type of therapy, this form is to help determine your eligibility. Should you not meet requirements, we will help you find the right therapy for your needs. You will hear back within one business day to your email and/or phone number entered below.

  • The best email to contact you. Please make sure that this email is confidential and only accessed by you and your partner.
  • Please ensure that we can leave a voicemail and text this number to ensure prompt and confidential communication.
  • Please describe why you are seeking couples therapy at this time.
  • While much of the intensive therapy can be done around schedules, time off from daily schedules is helpful and even necessary.
  • Do you both agree to the following: -If there has been an affair(s) that the affair(s) is(are) over completely. -To not file for divorce or work towards divorce in any way during therapy, but commit to working solely on saving the marriage. -That there is no current active drug or alcohol addiction. -That both of you acknowledge your individual contributions to the problems in your marriage, and that both of you are willing to address individual issues as part of the process.