Student/Client Name:*
*
Student/Client Email*
*
(May not be the same as guardian email)
Student/Client Phone Number*
*
Date of Birth
*
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Month
-
Day
Year
Date
Student/Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
High School
*
Graduation Year
*
Guardian Name
*
Guardian Phone Number
*
Guardian Email Address:
*
(May not be the same as student/client email)
Guardian Name (Optional for Additional Guardian)
Guardian Phone Number
Guardian Email Address:
(May not be the same as student/client email)
Please Select Service/Package:*
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Career/College Consulting: 1-Hour ($250)
Career/College Consulting: 3-Hour Package ($699)
8th & 9th Grade Package: ($1400)
Birkman Assessment ($849)
Comprehensive package (Grades 10-12) ($8000)
Senior Sprint ($5500)
Empowerment Coaching ($2000)
Preferred primary consultant*
*
Jigisha Doshi
Payment Preference*
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I prefer to pay by credit/debit card
I prefer to pay via bank transfer which has no additional fee
Payment Schedule*
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Enrolling in Comprehensive Package: prefer to pay half now, then quarterly payments thereafter. The last payment will be October of senior year.
Enrolling in All-Inclusive and prefer to pay in full now. ($100 discount will be applied)
Enrolling in another service and will pay in full
Enroll in autopay
I am enrolling in a payment plan and prefer to auto draft my payment method on file.
Appointment Policy*
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Clients cancelling or missing an appointment without 24 hours advanced notification will result in an additional $75 charge to the client. Frequently missed appointments may be considered a breach of contract.
Student Information: Does your student identify with any of these categories?*
*
Diagnosed Learning Difference(s)
Receives Special Accomodations at School
Gifted/Talented
Other Special Need
N/A
Special Circumstances: Is there is any specific information that we should consider while working with your student. Examples: Recent loss or transition, change in family or living dyanmics, special interests or talents, mental health diagnosis, disciplinary actions, etc.
Referral Source*
*
Referral
Presentation/Workshop
Internet Search
Other
If referral, please share their name or organization, so we can thank them.
I grant permission for consultant to speak to college admissions representatives on behalf of my student.
Yes, I grant permission
I grant permission for my photo to be used for marketing Sojourn Consulting
Yes, I grant permission
Agreed to sign on:
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Month
-
Day
Year
Date
Guardian Signature
PLEASE CAREFULLY READ THE SERVICE AGREEMENT FOR SOJOURN CONSULTING LLC LINKED BELOW:
SUBMIT
SUBMIT
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