Appointment Request
Please provide your name and contact information below.
Full, Legal First and Last Name *
Full, Legal First and Last Name
Contact Number *
Contact Number
Legitimate numbers only (i.e. no Google Voice or "burner" phone numbers)
Online Screening Service
If you are a member of one of the following screening services, please provide the necessary details I need to verify you.
Companion References
Please provide the name, email, and website address of at least two reputable companions you have spent time with.
Appointment Details
Please outline your appointment preferences below.
Requested Date
Requested Date
Preferred Time
Preferred Time
Miscellaneous Information