August 2018 - Neighborhood Connections

Partner Agency Referral Form
SMART Couples Florida
Participant’s Name: ____________________________ Cell Phone/Number: ______________
Address: _______________________________________ Email: ________________________
Partner’s Name: _______________________________ Cell Phone/Number: ______________
Marital Status:
Single Engaged Married Divorced Remarried
Program interested in:
Before You Tie the Knot Pre-marital training that after successful completion allows the
couple a $32.50 discount on Florida marriage license, and waives the 3-day waiting period
ELEVATE Take your relationship to the next level by learning the 7 core skills of an enriching
relationship
Smart Steps For those entering subsequent marital relationships involving children
Currently registered through SMARTcouples.org, Classes & Events page(Eventbrite)? Yes No
Referring Agency: ________________________________
Phone Number:_______________
Contact Name: __________________________________
Email: _______________________
SMART Couples Florida contact information: please email or fax this form to:
Nelly Nelson, BSM, MBA
Extension Agent
nelly.nelson@ufl.edu
(941) 722-4524 ext.233
(941) 721-6796 Fax
37
Revised December 6 th , 2016