Client Information Form

Name * Required

Student's Name

Email * Required

Student's Email Address

Phone * Required

Student's Phone Number

Address * Required

Birthday * Required

School * Required

Year of HS graduation * Required

Grade * Required

Mother * Required

Mother's email * Required

Mother's mobile phone * Required

Mother's Occupation

Mother's Employer

Mother's College/University

Mother's Degree/Major

Mother's Graduate School

Mother's Degree/Field

Father * Required

Father's email * Required

Father's mobile phone * Required

Father's Occupation

Father's Employer

Father's College/University

Father's Degree/Major

Father's Graduate School

Father's Degree/Field

Responsibility for Payment: The undersigned understands and accepts that the consultant’s fees are for their time and accumulated knowledge, that outcomes are not guaranteed, that the consultant’s services pertain only to educational, career, and personal coaching consultations, and should psychological and/or psychiatric terminology or codes be used, this should not be construed to mean that the consultant offers psychological or psychiatric services. The undersigned accepts that all fees are paid at the time service is rendered. Payment can be made by Visa, MasterCard, American Express or personal check. A facsimile signature below shall constitute the same as an original signature.

Electronic Signature

Relationship to Client * Required

Date * Required

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