All Questions marked with * are mandatory

How can I help you (Please describe the problem) *

 

 

  
Name you would like me to refer to you as *  
     

E-Mail address *
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Age *  
     
Gender *   Male Female
     
City / Country *   /
     
Are you currently in a relationship?   Yes No
     
How long has the problem/ issue been bothering you?  
 
How does the problem/ issue affect your life or the people around you?  
 
What have you already tried, to lessen the problem?  
 
What kind of things make you feel better?  
 
What things about your life are okay at the moment?  
 
If the problem were to miraculously go away, how would your life be different?  
     
 
     
     
 
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