Full Name (required)
    Email (required)

    Please double check you have entered this correctly; email is my primary method of contact

    Cell Phone Number (required)

    Please note I will not attempt to contact you on this number without your explicit permission

    Best way to reach you if I need to contact you just before the appointment? (required)

    Text MessagePhone CallEmail

    How did you find me? (required)


    Date You'd Like to Meet (required)

    How long would you like our first date to be? (required)

    What time would you like our date to start? (required)

    Shall I come to you? (required)

    City you'd like to meet in? (required)


    This section helps me get a feel for who you are and the kind of experience you’re looking for. Please answer each question in 3-5 sentences.

    Who are you? What brings you joy? (passions, hobbies, dreams, life’s work) (required)

    What qualities in another person most attract you to them (to me?)? What makes a great first date? (required)


    Review Board Name Followed by Your Handle OR Screening Site Name Followed by Your Member ID

    Option 1: References
    Please list the information for two providers with whom you’ve previously met.

    First Provider: Please include the name, email address AND website URL

    Second Provider: Please include the name, email address AND website URL

    If you are not able to provide me with any references, you may choose one of the following alternate methods (to be discussed via email, after you've submitted this form)

    Option 2: Employment Verification
    You will be asked for the URL to your company website where your name is listed. Verification can be done over the phone or over email. Please see the FAQ page for more information about this option.

    Option 3: Deposit and Phone Call
    I accept deposits via email transfer (my preference) or PayPal for international clients

    Option 4: ID and Photo

    Select Screening Option (I will follow up via email) (required)

    I have already listed referencesEmployment VerificationDepositID and Photo

    I agree to the cancellation policy (required)

    Questions, Comments? Is there anything else you’d like me to know about you or that would help me prepare for our time together?

Please note: If your submission was successful, you will receive an automatic confirmation email.