# Verbalist Intake Form

Help us customize your AI companion to best serve your needs

Step 1 of 5 20% Complete

## Personal Information

Tell us a bit about yourself so we can personalize your experience

What's your name? *
Please enter your name
How do you prefer to be addressed? *
Please enter your preferred form of address
What is your age range? *
18-30
31-45
46-60
61+
Please select your age range
How tech-savvy do you consider yourself? *
Beginner
New to technology
Intermediate
Comfortable with basics
Advanced
Tech enthusiast
Please select your tech comfort level

## Support Needs

Tell us about the primary support you're looking for from your AI companion

What is your primary reason for wanting an AI companion? *
Mental Health
Support for mental wellbeing
Dementia
Memory and cognitive support
Depression
Mood and emotional support
Anxiety
Stress and worry management
Loneliness
Companionship and connection
Business
Productivity and work support
Other
Custom purpose
Please select your primary reason
Please specify your purpose: *
Please specify your purpose
What specific challenges do you hope the AI companion will help with? * (Select all that apply)
Daily Tasks
Emotional Support
Memory Aid
Conversation
Learning
Motivation
Please select at least one challenge
What specific goals do you have for using an AI companion? *
Please share your goals

## Usage Preferences

Tell us how you plan to interact with your AI companion

How often do you anticipate using your AI companion? *
Multiple times daily
Once daily
A few times a week
Occasionally
Please select your anticipated usage frequency
When are you most likely to use your AI companion? * (Select all that apply)
Morning
Afternoon
Evening
Late Night
Anytime
Please select at least one time period
How would you primarily interact with your AI companion? *
Text Chat
Typing messages
Voice
Speaking and listening
Both
Text and voice
Please select your preferred interaction mode

## AI Companion Customization

Tell us how you'd like your AI companion to interact with you

What personality would you prefer your AI companion to have? *
Warm & Supportive
Empathetic and nurturing
Practical & Efficient
Direct and solution-focused
Cheerful & Optimistic
Positive and encouraging
Calm & Patient
Steady and reassuring
Please select a personality type
How should your AI companion communicate with you? *
Simple & Clear
Brief, straightforward
Detailed & Thorough
Comprehensive explanations
Casual & Conversational
Friendly, informal chat
Professional & Formal
Polished, respectful
Please select a communication style
What interests would you like your AI companion to be knowledgeable about? * (Select all that apply)
Health & Wellness
Arts & Culture
Science & Technology
History & World Events
Sports & Recreation
Food & Cooking
Business & Finance
Please select at least one interest

## Technical Setup

Help us configure your AI companion to suit your preferences

Would you like to receive notifications or reminders? *
Yes
No
Please select an option
What would you like to be notified about? * (Select all that apply)
Daily Check-in
Medication Reminders
Appointments
Activity Prompts
Motivational Messages
Please select at least one notification purpose
On which devices would you primarily use your AI companion? * (Select all that apply)
Smartphone
Tablet
Computer
Smart Speaker
Smart Display
Please select at least one device
Your Email Address *
Please enter a valid email address
Is there anything else you'd like to share about your needs?

## Information Submitted!

Thank you for providing your preferences. We'll use this to customize your AI companion experience.

To complete your registration, please continue to the payment page.

## Complete Your Registration

Secure payment to finalize your AI companion setup

### AI Companion Subscription

Monthly subscription $49.99
Includes unlimited access to your personalized AI companion

Total $49.99/month
Card Information
Cardholder Name *
Please enter the cardholder name

Your payment is secured through Stripe

## Registration Complete!

Your AI companion is now being personalized based on your preferences.

You'll receive access instructions by email shortly!

If you have any questions, please contact our support team.