Client Intake Form
Client Name:
Payee Name:
Contact Number (000) 000-0000:
Primary Email (Client):
*Must be Valid Email for Session Link:
Secondary Email (Payee):
*Must be Valid Email for Invoicing and Billing:
Service Desired (Choose ONE):
Tutoring / Test Prep (Individual; 1:1)
Tutoring / Test Prep (Group; 4 max.)
Workshops
Mentoring 18+
Lesson Planning / Curriculum Writing
HomeSchool Counseling & Advising
Professional Development
Business Consulting
Current Placement Level:
Infant-Toddler
PreK & Montessori
Elementary: Grades K-2
Elementary: Grades 3-5
Intermediate: Grades 6-8
High School Lower: Grades 9 & 10
High School Upper: Grades 11 & 12
AP Level: College Board Courses
Adult GED & Vocational Courses
Undergraduate Level (Associate's or Bachelor's)
Graduate Level (Master's / Other Certificates)
Doctoral & Seasoned Professionals Level
Special Accommodations or Needs:
Service Provider Preferences:
A Female service provider is preferred.
A Male service provider is preferred.
I do not have a preference.
Hometown, State (Example, ME):
Client's Time Zone (US only):
Eastern Standard Time (EST)
Central Standard Time (CST)
Mountain Standard Time (MST)
Pacific Standard Time (PST)
Hawaiian Standard Time (HST)
Alaskan Standard Time (AKDT)
Appointment Date / Time:
Referral Discount Code (Optional):
Bundle Your Service Package?
Yes, I'd like to save $20 and select a 4hr. Bundle
No, I'll start with just one service hour for now.
Desired Payment Method:
Debit Card (Visa, Mastercard, AmEx or Discover)
Credit Card (Visa, Mastercard, AmEx or Discover)
Bank Account (ACH Bank Transfer)
PayPal Account
Venmo or Zelle
Invoicing Notice & Consent of Services:
“I hereby offer my consent for Johntry Appleseed LLC to send me confirmation texts from OneSignal, and Invoice for services by email from Quickbooks Online, to the phone number and email address that I have provided on this Client Intake Form.” “I certify that I am the person, or have direct permission from the person, who will receive a Billing Invoice for these services and payment will be made in full within three (3) business days from receipt of invoice.” “Additionally, I understand that re-scheduling requests must be made in writing within 48 hours of my appointment time, or I will not receive a refund. Furthermore, I understand that services will be delayed or canceled if I am unable to pay my invoice in full before the time of service.”
Do you agree to the terms?
I Agree. Please Send my Invoice.
I Do Not Agree. Please Cancel my Appointment Request.