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NOTE:  This is a Double-Hammer Computer Services DEMO site, and is no longer active!
Please view with that in mind... information, forms and links may no longer be valid.
Copyrights may continue to be held by the original owners of the site.

New Client
Service Request and Assessment Form

Please fill in the following information as accurately as possible.
It is designed to help us serve you better.

 

The first time you "sign-up" with us, we will issue you a "Client Log-in Username" and Password.  Thereafter when you return for a Scheduled Session, or to request a New Session, you will only need to "log in" and submit your Credit Card information only.  You will not have to re-submit all of this information again.


rightarrow_red.gif (77 bytes) I have read and agree to all policies as described in the
    Service Agreement and Disclaimer:
Yes No

 

rightarrow_red.gif (77 bytes) I am at least 18 years of age: Yes No

Personal Information:
(Note:  fields marked  * *  are REQUIRED Information)
Name:   * *
Email: * *
Billing Address: * *
Add'l Address:
City: * *
State/Province/Country: * *
Zip/Postal Code: * *   (No hyphens or spaces.)
Daytime Phone: * *
Evening Phone: * *
Fax Number:

Payment Information:
(Required Information)

Card Type: * *
Card Number: * *
Expiration Date: * *
Name on Card: * *

Optional Information:

This information may help your Counselor in providing you the best possible advice. While it IS CONFIDENTIAL, fill in only the information with which you feel comfortable disclosing.
Gender: Male Female
Age:
Marital Status:
Children: Yes No
Race/Ethnicity:

Select the Counselor Type you are interested in...
Then the Type of Service...

(Your Credit Card will be charged based on what you select below)

 

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Desired Appt. Date: * *
First Choice Time: * *    (Little Rock, AR  Time)
Second Choice Time: * *    (Little Rock, AR  Time)

Since this is your FIRST time registering with Counselors Link, please enter your DESIRED Username and Password here... if your desired Username is already taken, we will issue one as close as possible to your request. If you do not enter a preference here, we will assign a Username and Password for you.
Desired Username:
Desired Password:

THANK YOU... for making an appointment with Counselors Link!

We will E-mail you back shortly with your Counselors Link Username and Password, and a "Confirmation Number" for this Transaction.  Our E-mail will also Confirm your Appointment Date and Time.

If you are requesting our "Need Help NOW" Personal Chat Service,  our E-mail will also give you "when and where" instructions for the chat.


Please review your information listed above for accuracy, then click "Submit" to send this form to us.

    



NOTE:  This is a Double-Hammer Computer Services DEMO site, and is no longer active!
Please view with that in mind... information, forms and links may no longer be valid.
Copyrights may continue to be held by the original owners of the site.

 
 

Copyright 1999 Counselors Link.com
Designed & maintained by Double-Hammer Computer Services
 
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This page last updated 09/04/11