Intake form

Name *

Email address *

What topics are you interested in discussing?

Please select at least one option.

Politics

Personal Life

Health and Wellness

Hobbies and Interests

Family

Travel

Technology

Current Events

How frequently would you like to have a chat?

What is your preferred method of communication?

What time zone are you in?

Are there any specific days you prefer for conversations?

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What age group do you belong to?

What is your preferred language for communication?

Which service or services are you interested in?

Please select at least one option.

Companion Calls

Venting and validation

Deep discussions

Additional questions or comments

Checkboxes

Please select at least one option.

I understand and agree to the Terms of Service and Privacy Policy, and consent to the use of my information to provide this service.

BoomerHelp