Intake Form Question Title * 1. I have read through, understand and agree to the confidentiality and policies notes on the link as per below: (if this link does not work, go to Michelepaiva.com and the POLICIES link. ) Agree Question Title * 2. Address Name Company Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number Question Title * 3. Primary concern that you wish to address. Question Title * 4. Secondary concern that you wish to address. Question Title * 5. Tell me about your romantic relationships. Past and present. What were the breakups like, were there any trends in men or women you attracted, what level of happiness and love do you experience on a daily basis now? Question Title * 6. What was the most traumatic memory or chronic struggle of your childhood? Question Title * 7. Who were the most important people in your childhood? (this might expand past family; maybe a teacher , etc) and why? Question Title * 8. Check off the physical and emotional struggles that you've had in the past or experience now, even if sporadic (but chronic). Insomnia (trouble falling asleep, mind racing or waking up in the middle of the night) Anxiety or panic Depression or emotional lethargy Any female hormonal struggles from PMS to PCOS, low libido, menopause struggles, pain... Any male hormonal struggles from performance anxiety or low libido, pain in the testicles, testosterone hikes in the form of anxiety with rage... Digestive struggles including a long list of items that don't agree with you, allergies or breakouts Skin struggles that include breakouts, hormonal skin, itching, disorders/conditions, cancer etc Other health struggles (autoimmune, etc) Lack of motivation, feeling empty, losing sight of purpose Feeling frazzled, too much on your plate Feeling betrayed, cheated on, doormat, used Feeling neglected, cast aside, undervalued Feeling like you want to take a deeper step in self-enrichment but not sure how/where You know of trauma or chronic stress from childhood including but not limited to a parent that was an addict, a sick parent or sibling, abuse or neglect directed at you and/or others... Other (please specify) Question Title * 9. EXTRA ISOLATION: Do you feel uncomfortable with isolation, finances, stress, anger, fear that you feel it might be translating into your day to day happiness? A great deal A lot A moderate amount A little None at all Question Title * 10. Add anything else about yourself that might be helpful for me to know. Done