NOTE: This is a Double-Hammer Computer Services DEMO site, and is no longer active!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.
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)
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.
I have read and agree to all policies as described in the
