First name *

Last name *

Email *

Phone *

Birthday *

Emergency Contact Information: *

Do you have a specific issue or concern that you are seeking help for?

Are you sensitive to perfumes or fragrances?

Are you sensitive to touch?

I understand that assistance through Socorro Diaz’s programs is not a substitute for medical advice or treatment. This is a soul-level work, and I will only proceed as long as I feel comfortable. It is recommended that I seek the advice of a medical professional for any physical or psychological symptoms I may be having. Socorro’s services merely complement any work done with a qualified medical professional.

Today's Date: *

Signature *