Website Design Intake Form - Fresh Design Studio

Client Service Request Form

Questions? Business Office Hrs (Monday Thru Friday 9 am - 5pm EST) Please Call 1 (800) 380 - 4305
Please Note: Service Requests Submitted Outside Our Normal Business Hours Monday thru Friday 9am - 5pm EST Will Be Reviewed The Next Business Day
Select request type
Reason for change or cancellation
Date of Original Requests

MonthDayYear
Date
New Date (If Applicable)

MonthDayYear
Date
Time of Original Requests

Hour Minutes

AM/PM Option
New Time (If Applicable)

Hour Minutes

AM/PM Option
Previous Pick-Up Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Pick-Up Address (If Applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Destination Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Destination Address (If Applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional comments or updates
Type a question
Name of person receiving services

First NameLast Name
Care Receiver Name

First NameLast Name
Name of person submitting this updated requests or cancellation

First NameLast Name
Best contact number of person submitting this updated requests or cancellation
Please enter a valid phone number.
Best Contact Number for Companion to Reach Client
Pick up Location or Service Address. *
Pick Up Date (Date Client Needs Service)

MonthDayYear
Date
Pick up time (Time Client Wants Driver to Arrive)
Please indicate if this is for a roundtrip or one way requests.(put n/a if it does not apply)
Client Destination and Appointment Time (if applicable)
Purpose or trip and duration of requests (2hr min). How long will they need the companion and where will they be traveling to? (just an estimate)
Referring Agency (ex. riverside, caring hearts, Jewish Family services etc)
Care Coordinator Name (if applicable)
Name of person submitting this request:
Name of Preferred Companion Driver (if applicable)
Contact Preferred Caregiver/Companion Driver

Sarene Waller 757 - 802 - 4246 ext 710

Fadrina Robertson 757 - 802 - 4246 ext 716

Dasheka Frazier 757 - 802- 4246 ext 717
Acknowledgement of terms and conditions:*

Submission of this form does not guarantee we can provide services on the date and/or time you’ve requested. A member of the scheduling team will send out notification to confirm or decline your request.
You acknowledge that requests made with 24 hours or less notice will be assessed a surcharge in the amount of $75 in addition to regular service fees charged for billable hours. To avoid this surcharge all service requests must be received Monday thru Friday during our business office hours of 9 am to 5pm est.
We do not guarantee that your preferred health worker will be available upon request as they are scheduled based on their availability.
Cancellation Fee and Policy A cancellation fee of $55 will be charged for all scheduled appointments not cancelled at least 1 business day before the scheduled appointment.Medical Equipment and Devices Please acknowledge that if you have a wheelchair, walker or rollator you understand these items must be collapsible and able to be stowed away safely in a non-wheelchair accessible vehicle such as a sedan, SUV or minivan.
Type a question
Should be Empty:

Client Service Request Form