Client Intake Form

Client Intake Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number (If no cell phone)
Please enter a valid phone number.
Email*
example@example.com
Type of Service Requested*

Recurring Service (Weekly)Recurring Service (Bi-Weekly)One-Time Deep CleanMove In/Out CleanOther (please specify)
If you ARE requesting a recurring service is there a day of the week/time of day that does NOT work for your recurring service day?

Monday MorningsMonday AfternoonsTuesday MorningsTuesday AfternoonsWednesday MorningsWednesday AfternoonsThursday MorningsThursday AfternoonsFriday MorningsFriday Afternoons
If you are NOT requesting a recurring service, is there a specific day, week or window of time you would like this job done in?
Square Footage of Home*
Square Footage of Area to be Cleaned (if different than entire home) *the more exact the square footage, the more accurate of a quote you will receive beforehand
Number of Bathrooms*
List of Other Rooms to be Cleaned
Do you have pets? How many/what kind?*
Do you requires Maid Service (Dishes/Tidying Up) ---(Additional charge only applicable for recurring service.)*

No, dishes will be done and everything will be put away upon arrival.Yes, but I'm unsure how longYes, 1-15 mins @ $15.00Yes, 16-30 mins @ $28Yes, 31-45 mins @ $40Yes, 46-60 mins @ $50Yes, 60+ mins
Do you*

Own a Canister Style Vacuum in Good Working OrderOwn a Central Vacuum in Good Working OrderRequire Use of Northern Upkeeps Vacuum
Have you had a Professional Cleaning Service before? If yes, when was your last service?
Tell us about your last service experience. What are some things you loved? What are some things you felt needed improvement?
Biggest areas of concern when it comes to cleaning and maintaining your home? Please also include any special considerations and/or details that we should know about your space.
How did you hear about us?*
Upkeep your space, Keep Up with your life!
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Client Intake Form

Upkeep your space, Keep Up with your life!