CLIENT INFORMATION/RELEASE & PERSONAL INVENTORY
City: State: Zip:
Telephone: Cell:  Home:
Date of Birth (mm/dd/yyyy):
Undergrad Institution: Yr. of graduation: Major:
Graduate School: Degree(s): Yr. of graduation: Major
Are you a reapplicant? If "yes," what year(s) have you applied previously?
How were you referred to me?
What year do you plan on matriculating into medical school?
PLEASE NOTE: I maintain client confidentiality and will NOT discuss our work together with anyone else - not your family members nor your friends. Please do not ask me to do so.
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 months. "Use it or lose it."
Electronic Communications. You agree that this Release constitutes "a writing signed by You" under any applicable law or regulation.
PLEASE RETURN THIS FORM TO ME PRIOR TO OUR WORK TOGETHER
Fees and other nitty-gritty information:
METHOD OF PAYMENT
I have a ONE (1) hour
minimum fee of $400, payable at least 24 in advance of our scheduled meeting.
A service charge of 1.5% per month is applied to
all balances not paid by the 30th of the month.
PLEASE MAKE SURE THAT I HAVE (all can be email-attached and sent to me):
IS IMPORTANT THAT I HAVE ALL THIS MATERIAL 48 HRS. PRIOR TO OUR WORK TOGETHER
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.)
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. COMMUNITY SERVICE INTO AN UNDERSERVED GROUP: As above, describe your involvement. Give details, including dates and weekly time involvement (hours/week).
9. 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).
10. WHAT ARE YOUR CAREER GOALS? Be as specific as possible.
11. WHAT DO YOU DO FOR FUN?
12. 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.
email this and any other attachments to:
January 9, 2019