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Search for Marriage Education Services
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Registration for Twogether Service Provider


1. Name of person completing this form.
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2. Who would we contact to update the information on this organization in the future.

 
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* Required Field
This field will appear on the business card.

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Your Organization Type in this box only.
This field will appear on the business card.

4. ADDRESS

What is the street address of your organization (main office)?

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Is this address confidential?  
Is this address a residence?  

What is the mailing address of your organization (main office)?

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Is this address confidential?  

This field will appear on the business card.
 

5. ORGANIZATION FUNDING

What are the sources of funding for the organization? Please choose all that apply.


6. Service Goals



 

TYPE OF SERVICE*

1. What type of marriage education do you provide?

2. How many hours is your program?*



**Other

3. What Type of schedule do you provide for your program?




 

NAME OF CURRICULUM*



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1. LOCATION SERVED

Please list the city/zip codes where this service is/are being offered.

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2. If you have one specific location where all services are offered, please complete this section.

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Address :
County :
 

Is this site accessible by public transportation (within 1/4 mile of a stop)?

    

Is this site accessible by wheelchair?

    

3. DAYS and HOURS of OPERATION

On what days and during what hours do you intend to offer services? (Check all that apply)
 

1. TARGET POPULATION


Do you offer services in Spanish?

     


Do you offer services in any other language(not English or Spanish)?

     


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2. FEES

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TypeNote
  
  


 

Complete ONLY if a program and you offer on-going registration

1. Person to contact to register:

 

Premarital Education Program Curriculum Certification

Please read the following user certification. You must accept the terms of this certification before continuing as a twogether in Texas service provider.

Name of the Organization :
Name of the Curriculum :

This curriculum meets or exceeds the criteria in compliance with Section 2.013, Texas Family Code. Specifically, the curriculum offered will be a minimum of eight hours and include instruction in:
(1) conflict management;
(2) communication skills; and
(3) the key components of a successful marriage

In addition, the curriculum offered meets or exceeds the requirements as stipulated
by statute provides the skills-based and research-based curricula of:
(1) the United States Department of Health and Human Services healthy marriage initiative;
(2) the National Healthy Marriage Resource Center;
(3) criteria developed by the Health and Human Services Commission; or
(4) other similar resources.


The services offered will be conducted by instructors trained in this skills-based and research-based marriage preparation curriculum.
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I hereby certify that the above information is a true and correct description of the Twogether in Texas Healthy Marriage services that will be offered by as a Twogether in Texas provider.

Name :  
Title :  
Telephone number :  
e-mail :  




Authorization to Publish Information

Please read carefully

Organization Name : 

In addition to relaying information about your organization’s services over the telephone, 2-1-1 Texas and Twogether in Texas will disseminate information in printed directories and in an online database, which is available at www.211texas.org. Many social service professionals and volunteers at churches, nonprofit organizations, schools, and government agencies use this information to refer their clients to organizations and programs. Please feel free to call us if you have concerns related to this form.

This signed release form will be retained on file as an ongoing authorization that 2-1-1 Texas and Twogether in Texas may provide information to the public regarding the services of the above-named agency.

, I hereby authorize Twogether in Texas and 2-1-1 Texas Information and Referral Network to utilize my organization’s information for inclusion in any print or online publications of community resources. Information that is noted as confidential on the agency/program forms will not be given to callers, nor will it be published in other formats.

, I do not offer classes for the general public so Twogether in Texas and the 2-1-1 Texas Information and Referral Network do not have authorization to print my organization’s information in any print or online publication of community resources. The information will continue to be provided to individuals who call the 2-1-1 helpline for assistance.


Verification :

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Name :  

Title :  

Date    5/20/2013

   

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