New Client Form

If you need to update just your credit card information, you can just input your name and the relevant information.

Please complete this form, so I can maintain your information. Your session is not booked without the collection of your session fee.

Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Credit Card Number
Expiration Date
Credit Card Security Code
Email*
Child #1 Name and birth date
Child #2 Name and birth date
Child #3 Name and birth date
Spouse name and any other children
Do any of your children have special needs?
If yes, please describe your child's diagnosis or special needs.
How did you hear about me? (Web search, magazine, friend, etc). If you heard of me through someone, please provide their name, so they receive their bonus.