VIVID Relationships: Couples

Interested in getting help from Dr. Viviana? Complete this application and we will get back to you.

Date*
MM slash DD slash YYYY
Your Name*
First Last
Your Age*
Your Email*
Your Phone*
Partner's Name*
First Last
Your Partner's Age*
Partner's Email*
Partner's Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have any children under 18 years old living with you?*
Please List Your Public Social Media Accounts*
If none, please type NONE
Current Relationship Status*
How long have you been a couple?*
Presenting Problem*
Please think about and share the overall issue you are struggling with as a couple. Because this is not in-depth therapy, the more general your summary is, the more likely I will be to include you in this project. Thank you in advance.
How did you hear about this project?*
Please Upload a Recent Picture of the 2 of You
Drop files here or

Max. file size: 500 MB, Max. files: 2.
Are you open to discussing having your work with Dr. Viviana documented?*
Saying "Yes" does not constitute consent. We will discuss this option further prior to recording anything.
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