Client Intake Form Mentoring & Tutoring Consultations Thank you for choosing to have a Mentoring & Tutoring Consultation with Colleáyn Klaibourne. These sessions are done via Zoom or by Phone. Information to send to Colleáyn at least 2 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. *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Gender *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 *~Questions for your SessionThis will give me an idea of your topics of interest and questions before your session so I can prepare 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 Spiritual Topics would you like to learn more about, study at a deeper level or gain more information & knowledge on? Please describe your reason for seeking a consultation at this time. *For example- Astrology, Angels, Qigong Healing Techniques, Meditation, Spiritual Boundaries, Feng Shui… What are your top areas of learning/tutoring/mentoring you seek, in order of importance. *What level of experience or knowledge do you have in these areas? *Please note, many of these areas of study may need more time than one session to go into depth of learning. Please share anything that will help prepare for our consultation, your goals, or that you would like me to be aware of. The more detail the better. *~Birth Information for Astrology Chart. (This is not required, but is very helpful for your session.)Please 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 PMAMPMSource of Birth DataEx. Birth Certificate (Hospital Record, Birth Record), Parental Memory, Baby book, Rectification from another Astrologer…. Your Birth Certificate is the most accurate. ~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. MessageSubmit