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Email me here:
Click here to Email Me
speakwithchi@aol.com

There are three methods that I use for screening , if you DO NOT have a provider reference or are not a part of a verifcation service such as RS2K, Date-Check or Preferred411, then you MUST provide me with employment information.

RS2k member, Date-Check or Preferred411 member are preferred you can provide me with the information associated to your account, for me to verify, as well as 2 provider references.

You may also use your TER or other review board handle with 2 provider reference. Please note to use this option you must have reviews, or be Whitelisted.

Use the sections below to provide this information, to input more than 1 provider reference you may use the comments field.

Please allow up to 24 hrs for an appointment, same day request are not available.

For our initial meeting have your ID available.

RED **Asterisk** are required information.

If you are having trouble viewing my form, or form is not loading properly, click the links above for alternate versions, or you may EMAIL ME this information below.

PERSONAL

Full Name:
email:
Home Phone:
Cell Phone:
Age:
Location: City, State, Zip Code

EMPLOYMENT INFORMATION:

Company Name:
Company Phone Number:
Your Direct Number:
Company Website Address:

APPOINTMENT INFORMATION
Desired Date:
Desired Time:
Alternate Date/Time:

WHERE AM I COMING?

I WOULD LIKE TO COME TO YOU/I WOULD LIKE YOU TO COME TO ME

HOW LONG SHALL I ACCOMPANY YOU?


PROVIDER REFERENCE: ONE:

Name:
Web Address:
Phone:
email:
Date Seen:

PROVIDER REFERENCE TWO

Name:
Web Address:
Phone:
email:
Date Seen:

RS2K, Date-Check, P-411 Member Information:


MISCELLANEOUS

Which Website did you find me on?

Are you a member of any review boards:

Member Name:


ADDITIONAL COMMENTS/SPECIAL REQUEST:


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