Intake 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.
Membership Information
Name*

First NameLast Name
Gender*
Phone *

Area CodePhone Number
Email Address*
Residence (City & State)*
How did you hear about us?*
Birthday*

MonthDayYear
Where were you born and raised?*
Ethnicity*
Religion/Faith*
Political beliefs*
Height*
Body type*

ThinAverageAthleticOther
Would you be willing to relocate?*
Do you Own or Rent your home?*
Educational level *
College attended (Name and Degree) *
Employer Name*
Occupation/Position*
Income (ballpark is fine)*
Do you smoke?*
Do you drink? How often? *
Have you ever been in trouble with the law? (This will not disqualify you from our services)*
Do you have children? (If yes, ages)*
Do you want children? *
Do you have pets? (Dog, Cat, etc)*
If you were married, or in a long-term relationship tell us why it ended?*
Do you speak any languages (besides English):*
Hobbies, activities, ways of staying in shape/being active*
3 Unique things about you (I won a Grammy, or I’m a gourmet cook)*
1
2
3
Tell us about yourself. This part is very important, and will be written in your profile for your matches to view (please write in FULL sentences, check your spelling/grammar and take your time): *
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)
Ethnicity*
Religion*
Political Beliefs*
Age Range*
Gender*
Describe your ideal match (very important, don't leave it blank)*
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)
Resolution should be less than 4MB and in jpeg format.
Photo 1*

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Photo 2*

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Photo 3*

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Photo 4

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I ACKNOWLEDGE AND CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. BY SUBMITTING BELOW, I CERTIFY THAT I'M AN UN-ATTACHED, SINGLE MALE OR FEMALE WILLING AND ABLE TO BE MATCHED UP WITH A POTENTIAL PARTNER, AND ENTER INTO A POSSIBLE RELATIONSHIP IF BOTH PARTIES AGREE. I AGREE TO ABIDE BY ALL THE RULES SET BY MATCH BY JULIA AND JULIA BENDIS, AND AS LISTED IN THE TERMS AND CONDITIONS ON MATCHBYJULIA.COM. I AGREE AND CERTIFY THAT I WILL DO MY DUE DILIGENCE IN KEEPING ALL PROFILES SENT TO ME BY MATCH BY JULIA AND JULIA BENDIS PRIVATE AND CONFIDENTIAL. I CERTIFY THAT I WILL NOT SHARE PRIVATE PROFILES WITH ANYONE NOR WILL I CONTACT THOSE INDIVIDUALS ON MY OWN, ON ANY SOCIAL MEDIA OR OTHERWISE. I ACKNOWLEDGE AND AGREE THAT ALL MEMBERSHIP FEES ARE NON-REFUNDABLE. IF I ENTER INTO A DATABASE MEMBERSHIP ONLY, THERE ARE NO GUARANTEES ON THE TIME FRAME OF POTENTIAL MATCHES FOR ME, NOR THE QUANTITY OF MATCHES. I ALSO ACKNOWLEDGE THAT BY AGREEING TO THIS CONTRACT, I AGREE NOT TO POST ANY PRIVATE EMAILS ONLINE OR ON ANY SOCIAL MEDIA, AND I WILL NOT POST ANY NEGATIVE REVIEWS FOR MATCH BY JULIA ON YELP, GOOGLE OR ON ANY OTHER SOCIAL MEDIA OR WEBSITE. FINALLY, I ACKNOWLEDGE AND AGREE THAT ALL MEMBERSHIPS ARE NON-REFUNDABLE AND NON-TRANSFERABLE. JULIA BENDIS AND THE TEAM AT MATCHBYJULIA.COM RESERVE THE RIGHT TO CANCEL YOUR MEMBERSHIP AT ANY TIME, AND FOR ANY REASON (MISCONDUCT OF ANY KIND WILL NOT BE TOLERATED).
Should be Empty:

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)

Resolution should be less than 4MB and in jpeg format.