Client Intake Form Astrology Consultation Thank you for choosing to have an Astrology Consultation with Colleáyn Klaibourne. * Each family member needs to fill out a separate intake form. These sessions are done via Zoom. Information to send to Colleáyn at least 4 Days before your session: I look forward to working with you. Client Intake Form Each field needs to be filled out completely in order for this formto be successfully submitted to Colleayn. Please enable JavaScript in your browser to complete this form.Today's Date *Name *FirstLastAddress *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Home PhoneE-mail *Date of Birth. *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *FemaleMaleRelationship Status *Occupation / Vocation. If Retired, Previous Occupation/ Vocation *The reason I ask for occupation is in case I’m seeing different work, hobbies, education, etc. that would be good for you to explore.Hobbies & Interests *~Birth Information for Astrology ChartPlease include your birth location, exact time of birth and if you were born in the am or pm.Date of Birth. *Please write out the month. For example: January 1, 1999 or March 2, 2011.Birth Location: City, State and Country. *Exact Time of Birth. *Exact birth time is required in order to create an accurate astrology chart.AM and PM *AMPMAge *Source of Birth Data *Ex. Birth Certificate (Hospital Record, Birth Record), Parental Memory, Baby book, Rectification from another Astrologer…. Your Birth Certificate is the most accurate. Have you had an astrology reading before? *YesNoOn a scale from 1-10 (1 – no knowledge, 10 = expert), what is your level of knowledge of astrology. *Current Location: City, State and Country. *~Questions for your SessionThis will give me an idea of your topics of interest and questions before your session so I can prepare and analyze your charts ahead of time. We will see how much we can cover during our session together because no matter how much time we have together, it never feels like enough!What are your top 3 things you would like me to focus on or talk about during our session? Please describe your reason for seeking a consultation at this time. *Ex. Health, Wellness, Career, Life Path, Year Ahead, Spirituality, Love, Relationships, Travel, Home, Education…What challenges/issues, stresses or concerns are you currently experiencing or new and exciting things you wish to receive insight on? *Is there anything else you would like me to know or feel would be helpful for me to know?~How did you learn about my work? How or by whom were you referred? *I have read & agree to the Notice & Client Bill of Rights *I have read & agree to the Notice & Client Bill of RightsI have read & agree to the Terms of Service & Privacy Policy ckgalleria.com collecting and storing my data from this form. *I have read & agree to the Terms of Service & Privacy Policy and consent to ckgalleria.com collecting and storing my data from this form.I am providing my electronic signature approving all the information entered. *I am providing my electronic signature approving all the information entered. Electronic Signature Definition.Type in Your Full Name *Thank you. ~Newsletter Sign UpIf you wish to be added to Colleayn’s newsletter, please click below or sign up on the “Home Page”. You can unsubscribe at any time. For more details, review our Privacy policyNewsletterPlease sign me up for your Newsletter.You can unsubscribe at any time. This information will be kept confidential and will not be sold or abused in any way. By clicking submit below, you consent to allow Colleayn Klaibourne to store and process the personal information submitted above to provide you the content requested.WebsiteSubmit
