Screening

* Required Field

About You

Name: *
Age: *
Ethnicity:
Body Type:
Occupation: *
How did you find me? *

Contact Information

Email: *
Phone: *
Accept SMS/Text? *
P411 Handle:

Appointment Details

Appointment Location:
Preferred Dates/Times: *
Preferred Length: *
Incall or Outcall: *
Outcall Location:
Traveler to this Area:
Any Questions or Special Request(s):
Minimum 2 Provider References (include each their names and contact info) - If no references, put N/A and fill out the next field: *
No references STEP 1: provide your LinkedIn link and work info here: *
No References STEP 2: Photo of you holding your ID/passport/drivers license:
Confirm you've read and agree to my cancellation policy and deposit of 20% to book an appointment? (see rates page): *
Yes

By completing and submitting this form, you are agreeing to all my policies on my RATES page. Screening plays an important role in confirming your time with me. Please be sure to fill out the form completely. I do verify the information submitted so please double check your responses. Your information will be kept confidential and will be discarded immediately after verification. Please understand that this process is for my safety and any haggling will result in termination of contact. Thank you! XOXO