VIVID Relationships: Individuals

Interested in getting help from Dr. Viviana? Complete this form in its entirety.

Date*
MM slash DD slash YYYY
Your Name*
First Last
Your Age*
Your Gender*
Your Email*
Your Phone*
Who do you think you could be a good match for?
Only answer this is you are applying to be considered as a potential match for our current client/s. LEAVE BLANK IF YOU ARE APPLYING TO BECOME A MATCHMAKING CLIENT.
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Upload a Current Unfiltered Face Picture*
Max. file size: 500 MB.
No filters needed.
Upload a Current Full-Body Picture*
Max. file size: 500 MB.
Current Relationship Status*
Have you ever been/Are you in therapy?*
What kind of dating help are you looking for?*
Please include what you're hoping to get out of your participation.
How did you hear about VIVID Relationships?*
Are you open to the idea of having your experience working with us documented?*
Saying "Yes" does not constitute consent. We will discuss this option prior to any recording.
By entering your FULL NAME in the space below you consent to having Dr. Viviana or a member of her team reach out to you regarding this project.*

You will also be added to her Email List and will have the option to unsubscribe should you ever want to.
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