Contractor Intake Form

Personal Information
Name*
Birthday*
Personal email address
Phone Number*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Policy:*
In the event that The Art of Applying is concerned that Contractor is in danger or is in danger of harming someone else, Contractor authorizes The Art of Applying to contact emergency services and/or Contractor's Emergency Contacts, and to provide them with any appropriate information relevant to the situation, including releasing Contractor's Emergency Contact information to emergency services. Contractor acknowledges that The Art of Applying is not providing psychotherapy or mental health counseling and is under no legal duty to report.
Emergency Contact Person*
Emergency Contact's relationship to you*
Emergency Contact's phone number*
Emergency Contact's email address*

Personal Information