THE JOURNEY BEGINS

We prioritize singles who are serious about achieving their relationship objectives. It is for this reason that we advise that you schedule a consultation when you are ready for the next step in your dating life.

There is a $150 fee. Should you decide to move forward, this fee will be applied toward your service.*

Read more on why we charge a consult fee. *Dating DIY is excluded

she/her, they/them, he/him, etc.

Name *

Preferred Pronouns *

Which country do you reside in? *

Address *

City *

E-mail *

I'm interested in *

How did you hear about Diaz Dating Group?

xxx-xxx-xxxx

Zip *

State *

Phone *

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BASIC INFORMATION

Recent Photos *

Upload your two most recent photos

Social Media *

Where are you from? *

Age *

Gender *

Preference *

Marital Status *

Relationship *

Sexual Preference

Marriage Story

Family Story: Children *

Do you have children? How many do you have? What are their ages? Do they live with you? Do you want more?

We are currently working towards expanding our database of non-monogamous and polyamorous singles. Unfortunately, we are not accepting new matchmaking clients with this relationship preference at this time. However, If you would like to be added to our database, we invite you to do so at diazdating.com/seeking. Membership is free! You are welcome to continue this form.

OPTIONAL: For LGBTQ+ Singles

OPTIONAL: How long were you married? How long have you been divorced or widowed?

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EMPLOYMENT AND EDUCATION

Education *

Explain Educational Background *

Current Job Title *

Explain Current Occupation *

Current Income Range *

Living Situation *

Have you worked with another matchmaker before? If so, describe your experience

OPTIONAL

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RELATIONSHIP HISTORY

When was your last long-term relationship? Why did the relationship fail? *

Rank in order the top 3 concerns that you have about dating or your partner search *

Why do YOU think you're single? *

Are there any specific dating requirements or needs we should be aware of? *

Are you currently working with a healthcare professional? *

Please share any medications you are on.

If I am working with a psychotherapist (which I have disclosed above), my practitioner knows that I am working with Jasmine Diaz or the Diaz Dating Group and that our work is not therapeutically based. I understand, and agree, that Jasmine Diaz or the Diaz Dating Group does not represent themselves as anything other than a coach. I am fully disclosing this information and I am not withholding information that is pertinent to my care.

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STATEMENT OF INTENT

I understand that the services I will be receiving from Diaz Dating Group, LLC, hereinafter referred to as "Diaz Dating Group," are not offered as a substitute for mental health care. I also understand that Diaz Dating Group is not acting as a psychotherapist and does not purport to offer mental health care.
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I understand that Diaz Dating Group will maintain the confidentiality of our communications only to the extent defined by the laws of the states in which each of us resides.
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I understand and agree that I am fully responsible for my well-being during my coaching or matchmaking sessions and, subsequently, my choices and decisions. I understand that all comments and ideas offered by Diaz Dating Group are solely to aid me in achieving my defined goals. I have the ability to give my informed consent and hereby give such consent to Diaz Dating Group to assist me in achieving such goals.
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I hereby release, waive, acquit and forever discharge Diaz Dating Group, LLC, Shawn Mackenzi Agency, their agents, successors, assigns, personal representatives, executors, heirs, and employees (collectively “The J.Diaz Co.,” “Diaz Dating Group” “Love by JD” or “Love by Jasmine Diaz”) from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of actions, omissions, or commissions taken by myself or by Diaz Dating Group as a result of the advice given by Diaz Dating Group or otherwise resulting from the coaching relationship contemplated hereunder.
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I further declare and represent that no promise, inducement, or agreement not herein expressed has been made to me to enter into this release. The release made pursuant to this paragraph shall bind my heirs, executors, personal representatives, successors, assigns, and agents.
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COMPETITION

I represent and warrant that I am not currently working or consulting for another matchmaking, networking, introduction, relationship, dating service, or related business and shall not use any of the Diaz Dating Group's confidential information, or solicit any of the Diaz Dating Group's workers, to establish a matchmaking, networking, introduction, relationship, or dating service or related business during or after this application.

Digital Signature *

Today's Date *

If you are unable to submit this form, please check all required fields

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