Rod Kochtitzky, M.Div - Couples Counseling, Nashville, TN - Send Rod Your Contact Info before the Initial Consult

Please fill out and submit the form below and be sure to add two or three possible dates for our initial consult at the end of this form. Also check out the "Frequently Asked Questions" (FAQ) for more info about the initial consult and for directions to my office.

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:

Number of years in current realtionship:

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