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Click Here to Start the Five Minute Exam. - Credit Card Payment Only

Patient First Name*
Patient Middle Name
Patient Last Name*
Gender*
- Male
- Female
Birthday
Month
Day
Year
Marital Status*
- Married
- Divorced
- Single
- Widowed
Phone (Cell Preferred)*
Email Address*
Enter Email Confirm Email
1) I am under high levels of Stress.*
2) I feel Overwhelmed by my current Life circumstances.*
3) I find myself feeling discouraged and pessimistic about my future.*
4) I find myself depressed and or saddened by my current life circumstances.*
5) I feel beat down and burnt out in my current life circumstances.*
6) I feel unhappy in my current life circumstances.*
7) I find myself worrying about my future, my finances, or my family.*
8) I feel frustrated and uneasy in my current life circumstances.*
9) I feel burdened by my current life circumstances.*
10) I find myself tense and up tight in my current life circumstances.*
11) My stress level is interfering with my work.*
12) My stress level is interfering with my sleep.*
13) My stress level is interfering with my ability to focus and concentrate on what I have to do.*
14) I turn to Alcohol, Food or drugs to comfort me in my current life circumstances.*
15) I am finding that Anxiety and restlessness are disrupting my everyday Lifestyle.*
16) I find myself irritable and often impatient in my current life circumstances.*
17) Do you find yourself lonely in your current life situation?*
18) Do you wish you had more and deeper emotional support systems?*
19) Does your stress level interfere with your communication with your loved ones, friends, or coworkers?*
20) I am subject to outbursts, Mood swings, or periods of negativity in my current life circumstances*
21) Which Life events have caused you significant stress this year?*
Step 1) Please describe your stress levels in detail -- Step 2) Please list any physicians that have prescribed medications or psychologist that you have seen or are seeing.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State ZIP Code
How many Pets
Pet #1 Type
Pet #1 Breed
Pet #1 Weight
Pet #2 Type
Pet #2 Breed
Pet #2 Weight
Pet #3 Type
Pet #3 Breed
Pet #3 Weight
Rush Option*
Pick Your Plan*
- Housing/Travel Plan $199
- Housing Plan $159
- Travel Plan $149
Total
$0.00