Counselors Review Journals

	COUNSELOR REVIEW FORM - Required fields are marked by an asterisk (*)

	Contact Name:*

	Business Name:*

	Email address:*

	Mailing Address:*

	City:*

	State:*

	Zip Code:*

	Country If not in the United States, please enter your Country.

	Daytime Phone:*

	Evening Phone: (Optional)

	What is your average number of clients per year?* Only enter the number of potential journaling clients.

	Will you be purchasing journals for your clients?* Enter (YES or NO)

	Will your clients be purchasing their journals?* Enter (YES or NO)

	How did you hear about our website?*

	After you review the journal will you give us your feedback?* Enter (YES or NO)

	Promotional or Discount Code:

	Thank you for completing the counselors journal request form. We have a free journal daily quota of 7%. Your free journal will ship within 7-10 days if the quota has not been reached at the time of your form submission. If the quota has closed at the time of your submission, you will receive a separate email offering you The Addiction Recovery Journal at a discount. The email will contain a special discount code assigned to this submission only. Please be sure to enter that code when making your purchase.

COUNSELOR REVIEW FORM - Required fields are marked by an asterisk (*)