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Client Information and Release & PERSONAL INVENTORY
Name: Address: City: State: Zip: Telephone: Cell: Home: Email: Date of Birth: Undergrad Institution: Yr. of graduation: Major: Graduate School: Degree(s): Yr. of graduation: Major Occupation: How were you referred to me? What year do you plan on matriculating into medical school?
Additional information you feel I should know: This release and disclaimer is additional consideration for the professional services of Judith J. Colwell. The undersigned acknowledges and agrees as follows: By this document, the client whose signature appears below agrees to release Judith J. Colwell, her legal representative, and assigns and discharges same from all claims, demands, or actions by the client, on the basis of the discussions and interpretations of Judith J. Colwell. Consideration for this release and disclaimer of liability on behalf of Judith J. Colwell, shall be the services rendered by Judith J. Colwell. The client acknowledges that the consulting provided by Judith J. Colwell is not be construed as prophetic and acknowledges that such consulting provides freedom of personal choice at all times. There is no guarantee, implied or otherwise, that the consulting services provided by Judith J. Colwell, will enhance admission to medical school. There is a $25 charge for returned checks. Credit time balance expires after four (4) months of inactivity unless prior arrangements have been made. Electronic Communications. You agree that this Release constitutes "a writing signed by You" under any applicable law or regulation. Signature: Date: PLEASE RETURN THIS FORM TO ME PRIOR TO, OR AT, OUR FIRST CONFERENCE FEE STRUCTURE Fees and other nitty-gritty information: I have a TWO (2) hour minimum fee: $550,
paid in advance if you are a distant client, or at the time of our first
conference if you are a local client. Our first conference is usually
an hour conference. All work thereafter is charged on strictly a time-spent
(pro rata) basis at the rate of $275/hr., paid in advance.
There is no refund of unused time credit. For my local clients, you may choose to meet in person, or I will call you and we will have a telephone conference. The time we schedule is for you exclusively, and therefore I require a 24 hr. cancellation notice. (Missed appointments are charged in full.) For my distance clients where we converse by phone (Continental US and Canada) (or occasional email), I work on a retainer basis. Each "round trip" consulting email usually constitutes 5-10 min. of consulting time and is billed as such. (Missed appointments are charged in full.) METHOD OF PAYMENT
Additional hours are charged at $275/hr. on a paid-in-advance, pro-rata
basis. There is no refund for partial hours unused. A service charge of 1.5% per month is applied to all balances over 30 days. Signature: Date:
Prior to, or at our first consulting conference PLEASE MAKE SURE THAT I HAVE (bring with you or fax/email/mail to me) copies of your:
IT
IS IMPORTANT THAT I HAVE THIS MATERIAL 24 HRS. PRIOR TO OUR FIRST APPOINTMENT
PERSONAL INVENTORY Your Name:
Date You Completed This Inventory: (Please be sure to keep a copy for yourself.) In order for us to discuss both your strengths and possible areas in which you may need to concentrate more of your resources, please complete this inventory and make sure that I have it either prior to, or at, our first conference. Use as much space as you need, within reason. Type or cut-&-paste from a word processing program. If you have no experience(s) in various areas, please say so. Don't "create" something just to fill in the blank(s). That won't help us in our assessment. 1. EMPLOYMENT HISTORY: (Please list all paid employment during/since college.) List most recent experience first. Be specific. Include dates and number of hours worked. (Feel free to include a resume - for this question only.)
2. LEADERSHP/MEMBERSHIP: a. Have you initiated any new programs or ventures? (This can include sports programs, clubs, business, activities, classes, etc.) Give details, including dates and weekly time involvement (hours/week).
b. Have you held a leadership position in any organization? Give details, including dates and weekly time involvement (hours/week).
c. What, if any, organizations have you been an active member? Give details, including dates and weekly time involvement (hours/week).
3. SCHOLARLY PROJECTS: Describe in detail any scholarly pursuits and projects (this could include research, honors project, thesis, or other scholarly endeavor) that you have accomplished. Give details, including dates and weekly time involvement (hours/week).
4. ARTISTIC PROJECTS: Describe in detail any artistic projects that have been important to you. (Theater, fine arts, music, woodworking, etc.) Give details, including dates and weekly time involvement (hours/week).
5. AWARDS and HONORS: If you have received any awards, honors, and/or citations, please describe in detail. (Publications, poster presentations, exhibitions, performances, etc.)
6. PERSONAL INTEREST(S): Of all that you have described above, which ONE activity has interested you the most, or held the most meaning for you. Please describe in detail why this is so.
7. CLINICAL EXPERIENCES: Please be specific as to any or all clinical experiences you may have had (hospitals, nursing homes, suitcase clinics, etc.) Give details, including dates and weekly time involvement (hours/week).
8. SERVICE TO OTHERS/TO THE COMMUNITY: Describe your involvement in volunteer activities, caring experiences, community service (separate from any clinical activities mentioned above). Give details, including dates and weekly time involvement (hours/week).
9. WHAT ARE YOUR CAREER GOALS? Be as specific as possible.
10. WHAT DO YOU DO FOR FUN?
11. WHAT ARE YOUR EXPECTATIONS DURING OUR WORK TOGETHER? In order that I may help you in the best way possible for each of us, please tell me - being as specific as possible - what you expect from me, from our work together, and what you expect from yourself in this process.
Judith J.
Colwell, MA Last updated:
March 19, 2008 |