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 H.A.D.S Questionnaire 
If you have questions, or would like more information, please leave your name and contact information. To contact me directly call 407-453-1295

First Name:
Last Name:
Email Address:
Phone:
Address:
City:
State:
Zip Code:
Comments:
Do you have children:
How long were you married/seperated
Describe your level of discomfort:
1: mild
2: moderate
3: severe
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    P.R.E.S.T.I.G.E. Way of Life, INC.
    PO Box 720897
    Orlando, Florida 32872-0897
    Email:     lj@prestigewayoflife.com