Dateline-NBC TV Viewer Reaction Form

We're interested in your reactions and feedback about the DateLine-NBC TV special on "sexless marriage," featuring our Crucible Approach® Intensive Therapy Program. You can register to receive information about our offerings, talk to us about the television show, or express interest in our ongoing projects.

(MFHC does not sell your information to others. Release of information occurs only when appropriate to comply with the law, enforce or apply our Conditions of Use, or protect the rights, property, or safety of our users and others.)



Contact Information

* = Required Field
Mrs/Ms/Mr/Dr
First Name *
Last Name *
E-mail address *
Day Phone
Evening Phone
Would you like to join our e-mail list? Yes   No *


Tell us what you think

Did you see the 2006 Dateline-NBC TV show on "sexless marriages?"*
Yes   No

Reactions to the show (and other messages)


Participate in similar programs?

(Must be 21 years of age or older)


Are you interested in participating in a similar show on treatment-free basis?
Yes   No

Are you interested in participating in reduced-fee private treatment as part of a scientific research project?
Yes   No


Tell us about you

(Required if interested in participating in future programs or research, optional for everyone else)

Your Age
Partner's age
Current relationship status
Years with current partner

Your Gender
F   M

Partner's gender
F   M

Currently in committed relationship?
Yes   No

Living together?
Yes   No

Number of children

(The following ensures that a person, not an automated program, is making this request)

Enter the sum of 2 + 2:







Marriage and Family Health Center