Client Information Form – Dr. Steven Mercer

We respect your family’s privacy. The information you provide below will be used exclusively by Mercer Educational Consulting, LLC to assist with your educational needs. Your information will never be shared with an outside party.

Date*
MM slash DD slash YYYY

Student Name*
First Last
Home Address*
Street City State / Province / Region ZIP / Postal Code Country

Email and phone are two of the most important ways that Mercer Educational Consulting, LLC shares critical information with students. Therefore, we require a unique email address and mobile number for the Student and a separate email address and phone number for the Primary Parent Contact.
Student Email Address*

Home Phone*
Student Mobile*
Date of Birth (mm/dd/yyyy)*

Current School*

High School

College
School Name*

Year of High School Graduation (Expected)*

Expected Year Entering or Transferring to College*

Lives With*

One Parent

Both Parents

Other - Please Specify:
Other*

Nationality*

Language(s) spoken at home

Primary Parent Contact
First Last
Relation to Student

Mobile
Work
Email

Occupation

College(s) Attended

PARENT/GUARDIAN NAME
First Last
Relation to Student

Mobile
Work
Email

Occupation

College(s) Attended

Alternate Address
Street Address City State / Province / Region ZIP / Postal Code Country

All fields with an asterisk (*) are required to submit
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