1 Question Astrology Consultation Client Intake Form - Colleayn Klaibourne Astrology, Healing & Artistry

Thank you for choosing to have an Astrology Consultation with Colleáyn Klaibourne.

This session is a 10-minute video-recorded consultation sent to you via email.

Information to send to Colleáyn at least 4 Days before your session:

This Client Intake Form. *All fields are required.
Payment (Pay via website or Colleáyn can email you a PayPal invoice. If you prefer to send a check before the session, email Colleáyn for the address.)

Client Intake Form

Today's Date *

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Cell Phone *

Home Phone

E-mail *

Date of Birth. *//

Gender *

Female
Male

Relationship 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 *

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Birth Information for Astrology Chart

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 PM *

Age *

Source of Birth Data *

Ex. Birth Certificate (Hospital Record, Birth Record), Parental Memory, Baby book, Rectification from another Astrologer....

Current Location: City, State and Country. *

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Questions for your Astrology Session

Your Question. Please make your question as clear as possible. *

Please give enough information so I know what you are asking about. (It helps me so I understand it as clear as I can.). This type of email consultation is not good for “general outlooks”. If you ask a general question, the information that pops from your chart will refer to your Sun, Moon and Ascendant and refer more to your personality, “feeling” style, and natal strengths overview.

Is there anything else you would like me to know or feel would be helpful for me to know? *

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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 Rights

I have read & agree to the Terms of Service & Privacy Policy qigong.ckgalleria.com collecting and storing my data from this form. *

I have read & agree to the Terms of Service & Privacy Policy and consent to qigong.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.

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