Client Intake Form “Wellness & Well-Being” Astrology Consultation Thank you for choosing to have a “Wellness & Well-Being” 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. *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *GenderMaleFemaleRelationship 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 topic 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!Please describe the reason you are seeking a consultation at this time. Please share anything that will help prepare for our consultation or that you would like me to be aware of. The more detail the better. *What are your goals or what do you hope to receive from your session? The more information you share, the deeper I can look at what is happening.What are your top 3 things you would like me to focus on or talk about during our session in relation to your health & well-being? *What challenges/issues, stresses or concerns are you currently experiencing or concerned for in the future? *Are you currently seeing any other health care practitioners? *PhysicianPsychologist/ PsychiatristTherapistNaturopathChiropractorMassageHomeopathEnergy WorkerOtherCurrent Medications/ Supplements and for what condition? *Is there any chance that you are pregnant?YesNoInformation for if you are having a consultation with Qigong healing. Major Medical: Please list all significant illnesses, cancer, surgeries, accidents & traumas, and their approximate dates: *This is for your healing session and see the big picture of things. For current issue you, please provide as many significant or important timelines/dates involved with exact dates & times, if known. (Past, Present, Future). *For example: Dates of when you got sick or injured, dates met with specialists or received a diagnosis, tests, surgery dates. (Knee surgery, 9/14/23 at 8:00 am in Rochester, MN.) Please check the boxes to indicate if you have the following conditions. *ADHDAllergiesAlzheimer’s / DementiaAnemiaAnxietyArthritisAsthmaAutoimmune ConditionsBladder ProblemsCancer in PastCancer within Last 2 YearsCeliac DiseaseChemical SensitivityChronic PainColitis/ Crohn’sCOPDDepressionDermatitis/ Skin TroublesDiabetesDizzinessEndometriosisEpilepsyFatigueFeeling StuckFood Allergies/ IntolerancesForgetfulness/ Memory ProblemsGERD/ HeartburnHeadachesHearing ProblemsHeart/ AnginaHepatitisHigh Blood PressureHigh CholesterolHip/ Knee ReplacementHormonal ImbalanceInfectionInfertilityInsomniaKidney DiseaseLigament/ Tendon ProblemsLow Blood PressureLung ProblemsLupusLyme’s DiseaseMultiple SclerosisNeck/ Back/ Joint PainNerve/ Muscle DiseaseNeuropathyOrgan TransplantOsteoporosisOverweightPancreatitisParasites/ GiardiaParkinson’sPOTS/ DysautonomiaProstate ProblemsReproductive ProblemsSeizuresSkin CancerStrokeSurgery in the Last 2 YearsTeeth TroublesThyroid ProblemsUlcersUnderweightVision ProblemsVitamin DeficienciesOthers not listed or information you feel would be helpful for me to know. Feel free to add details to conditions checked above if needed. If you have food allergies, intolerances, digestive symptoms or weight imbalance, do you follow a special diet? Ex. Gluten free, Dairy free, Ketogenic, LCHF (Low Carb, High Fat), Grain free, Corn free, etc. Surgery Sessions: Please add the City and State where surgery will be, hospital name, dates of surgery, expected time in hospital, etc. For individuals who are having healing sessions before, during and after surgery. ~Birth Information for Astrology Chart. *Required for Zoom Healing Sessions*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 or PM * *AMPMSource of Birth Data * *Ex. Birth Certificate (Hospital Record, Birth Record), Parental Memory, Baby book, Rectification from another Astrologer….~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. 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