Client Registration Intake Form

Client Intake Questionnaire
Personal Information
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
What is the best time of day to call you?* .
Email*
example@example.com
Birth Date*

MonthDayYear
Rent and my lease ends 3 - 6 monthsRent and my lease ends 9+ monthsOwn a home I plan to sellOwn a home I plan to keep
Property Preference
To PurchaseFor RentTo InvestmentOther
New Building3 - 5 years6 - 10 years11 - 15 years16 - 20 years21 - 30 years30+ years
0.511.522.533.545+Other
0.511.522.533.545+Other
less than 500500-1,0001,500-2,0002,500-3,0001,000-1,5003,500-4,0005000+Other
PreschoolElementary SchoolMiddle SchoolHigh SchoolCollegeHospitalGymMetro StationBus StationParkShopping CenterOther
Pet-friendlyGymChildren's playroomWasher/DryerStorageParking SlotGarageBasementFire PlaceDeckSecurity SystemSwimming PoolWood FloorsUpdated HeatingUpdated PlumbingUpdated WiringFurnitureOther
Appointment
Should be Empty:

Client Intake Questionnaire