Information Full Name*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Spouse's Phone*Email* Spouse's Email* Marital Status*Wedding Date* Years Married*Religion*Languages Spoken* Children Names and Ages of Our ChildrenNames and Ages of Wife's ChildrenNames and Ages of Husband's Children A Little Bit About Your Relationship Briefly describe your relationship with your partner:What are the issues you struggle with the most as a couple?What do you hope to get out of the workshop?How did you hear about Date Nights with Betsy?*Is there a history of addiction for either spouse?*Do either of you drink, do you feel as if it is appropriate to serve wine?* Verification CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
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