Please submit the following:

To book time with me, please submit the following information.
This is a secure and encrypted form, and all information will remain strictly confidential. Please note that the more information you give me, the faster we can move forward. :)
Full Name*

First NameLast Name
Desired Date*

MonthDayYear
Desired Time

:HourMinutesAM/PM Option
Desired Option*
Please Specify*
Location of Desired Engagement (City, State)*
Will you host, or will I?
E-mail*
Board Memberships and Handles
Phone Number*

Area CodePhone Number
Safe to call and text you here?*

Yes, call and textNo, neitherCall onlyText onlyOther
(Please note that I will not communicate with you by phone in any way unless it is prearranged, including a text or call- your choice- en route to our engagement)
Alternate Number

Area CodePhone Number
Please Specify
City of Residence*
Occupation*
Employer
Employer's Main Number

Area CodePhone Number
Employer's Website
Reference 1 (Name, website)
Reference 2 (Name, Website)
Reference 3 (Name, Website)
Please introduce yourself and tell me why you'd like to meet.*
How did you find me? (i.e., Google search, Eros, etc.)*
Cancellation Policy: If you must cancel our engagement at least 48 hours or more before we are scheduled to meet, I'll be sad, and I will require a 50% deposit to reschedule. If you can only give me 47 or fewer hours' cancellation notice, or it is your second time canceling, I will be heartbroken, and I will require a cancellation fee of 50% of the scheduled engagement and you will have to prepay 100% of my rate to reschedule. If I have to cancel, which is rare, I will make it up to you with an extra hour the next time we meet, as well as a full refund of any prepayments.
"I have read and agree to your cancellation policy. I understand that any money paid to you is for time only."*

Yes
Enter the message as it's shown*
Should be Empty:

To book time with me, please submit the following information.