New Client Screening

If this is your first time seeing me, please make sure you have read and understood both Etiquette, and FAQs pages. Fill out the form below to the best of your ability.* Keep in mind that the more information you provide, the easier it is for me to verify you…meaning the sooner we can get started on our date! 🙂

**My guarantee to your privacy: Date discretion and protection is super important to me. All information you provide for screening will be kept purely confidential. Information is used by me and only me for verification purposes ONLY.

After filling out this form, please be sure to make an appointment request here.

______________________
SECTION #1: GENERAL INFO

 

______________________
SECTION #2: WORK INFO

 

______________________
SECTION #3 - REFERENCES (Name at least 2)

:::Provider 1:::

-----------------------
:::Provider 2:::

-----------------------
:::Provider 3:::

______________________
SECTION #4: REVIEWS / OTHER

______________________