Pre-Approval for clients

IF YOU HAVE ALREADY SUPPLIED THIS INFORMATION
PLEASE VERIFY WITH US VIA PHONE BEFORE FILLING OUT THIS FORM
You will also be asked for identification upon arrival at your first appointment with us.

We would be happy to accept references from REPUTABLE independents and agencies as a form of verification.
If you are not willing to provide this information then we kindly ask that you seek companionship elsewhere.
We assure you that all information is NEVER saved or used in any dishonest way.
 NO NAME, NO CONTACT NUMBERS, NO ID, NO APPT NO EXCEPTIONS!
Name:
Address
City, State, Zip
Work Phone
Cell Phone
First Email Address
Second Email Address
Place of Employment
Occupation
Preferred Contact Method
Provider Preference 1
Provider Preference 2
Reference (Provider or Agency)