Form
Please fill out the form below to start the process. After you fill it out, you will be directed to book a Consultation Call which enables us to set time aside and get to know you and your needs. After the consultation, we will be able to put together different membership options for you. Looking forward to helping you with all your relationship and dating needs! This intake form is FREE of charge and for information purposes.By filling out this form, you agree to abide by the set rules as described in Terms & Conditions, including but not limited to those listed in Terms & Conditions.You understand that all memberships are non-refundable. Should you decide to do a charge back and ask for a refund from your credit card company, we will be invoicing you for the full amount and for the fees incurred during the transaction. Please understand how tedious this process is and how much time it requires: consultation, interviewing you and your potential matches, screening, meetings, getting to know you and your desires not to mention time involved in putting together each profile. We take matchmaking and coaching very seriously, as well as every individual's desires and needs.
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Membership Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Best Time to Contact
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Gender
*
Where were you born and raised?
Ethnicity
*
Religion/Faith
*
Educational Level
*
Occupation
*
What is your income
*
Less than $80,000
$80-100k
$100-150K
0ver $150K
Current relationship status
*
Single
Married
Divorced
Situationship
It's complicated
Height
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Body Type
*
Slim
Average
Athletic
Curvy
Muscular
Full figured
Petite
Political Beliefs
Why do you think you're still Single?
*
Would you be willing to relocate
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Yes
No
Do you smoke?
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Yes
No
Do you drink? if so how often
*
Do you have children? How Many? (If yes, please provide details of ages)
*
Do you want children
*
Are open to dating someone with children? if yes, provide details
*
Do you have pets? (Dog, Cat, etc)*
Do you own or rent your home
*
Have you ever been Married or in a long-term relationship? if yes, please provide details of how long and why it ended?
*
What are your favorite Hobbies, activities, ways of staying in shape/being active
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Describe any pertinent family background and cultural upbring
*
Are you open to long-distance relationship if the right match is found?
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Languages Spoken
What are three things that you value the most?
*
What is your favorite TV Show/Movie?
What are you passionate about?
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What is your proudest accomplishment?
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Last Serious Relationship: Have you ever used an online dating service and/or Match maker?: How is that working out for you/how did that work for you?:How have you been meeting people in the past?:What have been your obstacles in finding someone: work hours, kids at home, isolation, exposure, poor choices?:
What have been your obstacles in finding someone: work hours, kids at home, isolation, exposure, poor choices?:
How have you been meeting people in the past?
Have you ever used an online dating service and/or Match maker?
How is that working out for you/how did that work for you?:
What kind of music do you like?
*
What is your love language?
*
How do you define success?
*
What are your thoughts on online dating and dating apps?
*
How would you best describe your Character?
*
Describe your personality in few words
*
Tell us about yourself. This information is very important and will be displayed on your profile for potential matches to see. Please ensure you write in complete sentences, meticulously check your spelling and grammar, and dedicate time to crafting your introduction
*
What does a Healthy Relationship look like to you?
What social media platforms do you use most?
Please attach at least 3 recent, different pictures of yourself. A full body and head shot (Do NOT attach shirtless selfies or pictures with other people, please crop them out. If you don't have good photos, we will set you up with our photographer, these are for our eyes and for informational purposes only)
Service Needed:
Coaching
Matchmaking
Both
Service Type:
Database Member
Membership
Describe your ideal PARTNER in detail. What are you looking for in a PARTNER: (if you're interested in coaching only, type N/A in all fields or set up a Consultation instead of filling out this form)
this part is very important
Ethnicity
Religion
Age Range
Body Type:
Geographical Location
How important is physical intimacy for you
List your top 5 Must have qualities in a potential partner Deal breakers of Non/negotiables?
Is there anything else you want us to know about you or your ideal partner?
How important on a scale of 1-10, is it for you to find a healthy and successful long-term relationship?
Are you able to make the time commitment and financial investment of working with a matchmaker?
Is there anything preventing you from getting started at this time?
I hereby affirm and declare that the information provided above is accurate and truthful. By proceeding with this submission, I confirm that I am single and open to being matched with a potential partner, with the understanding and willingness to pursue a relationship if mutually agreed upon. I commit to adhering to the guidelines established by Busola Akins LLC, as detailed in the Terms and Conditions.Furthermore, I pledge to responsibly handle all personal profiles shared with me by Busola Akins LLC, treating them with the utmost confidentiality. I will not divulge this information to others, nor will I independently contact any individuals from these profiles on social media or through any other means. I recognize and accept that all membership fees are non-refundable. In opting for a database membership, I understand that there are no assured timelines or set number of matches.Additionally, by agreeing to this contract, I promise not to disclose any private correspondence online or engage in posting negative reviews about Busola Akins LLC on platforms like Yelp, Google, or any other social media or websites. I acknowledge that memberships are non-refundable and non-transferable. Busola Akins LLC reserves the right to terminate my membership at any given time and for any reason, emphasizing that any form of misconduct will result in immediate cancellation.
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