Your Information *

First Name

Last Name

Your Phone *

(###)

###

####

Client/User #1 *

This is who the service is for

First Name

Last Name

Client/User #2 *

First Name

Last Name

Couple's Phone Number *

(###)

###

####

Do any of the members have an email address? *

Yes, and I will provide it in the field below

No

I am not sure

Tell us what technology the client has.

iPhone

Android Phone (Samsung, LG, Google, etc.)

iPad

Tablet (Samsung, Microsoft, etc.)

Apple (Mac) Computer/Laptop

PC Computer/Laptop

I don't know

Other (Type devices below)

What would the client like to focus during the initial Get Started session?

Learn how to use a device

How to download an app

Something's not working

Learn how to use Zoom

Other (Type ideas, issues or topics below)

Do you know any accessibility constraints that we can help address with their technology? Please check all that apply.

Vision

Hearing

Mobility