Astrology Consultation Questionnaire

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Name* This field is required.
First Name
Last Name
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Preferred Pronouns (optional)
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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What kind of engagement are you complete this questionnaire for?
1:1 Birth Chart Consultation
Astro Parlor (online)
Astro Café (private, in person)
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Hello there! I am excited to meet with you to discuss your astrological profile and explore what insight it might provide for you. Your completion of this questionnaire gives me the information I need to prepare for our time together, as well as how I might shape the consultation to meet with your specific experiences and desires. Thank you in advance for your responses!
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Hello there!

I'm excited to see you at the private Astro Café event being hosted on November 7. By completing this questionnaire, you are providing me with the information to have your birth chart prepared for the event and maximize the time we can discuss the insight it can provide.

Thank you in advance for your responses!
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Date of Birth* This field is required.
Date
Year
Month
Day
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Location of Birth (i.e. City, State)* This field is required.
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Do you know your time of birth?* This field is required.
Yes, I have the time recorded on my birth certificate (or something very, very close).
I have an estimated time based on the memory of a family member.
No, I do not know my birth time.
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Time of Birth (please include AM/PM)
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Estimated Time of Birth: Please feel free to give a time of day (i.e. sunrise, late afternoon, etc.) or a time range (if giving time(s), please include AM/PM).
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Do you have any prior experience with astrology? Have you received any consultations in the past? Have you studied or read about astrology?* This field is required.
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What particular question(s) or life circumstance(s) are you interested in discussing during your reading?* This field is required.
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Please provide a brief biography outlining major time periods, events, and transitions in your life. Please include information about your family (parents, siblings, etc.), as well as any details about your birth of which you are aware.
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How would you like to meet for this consultation?
Google Meet (I will provide a link)
In person (Greater Pittsburgh area only; I will reach out, and we can select a meeting place)
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PAYMENT INFORMATION

Cost for a reading at the Astro Café is $30. You can:

1. Pay in advance via Venmo (@lee-saville-iksic) or Cash App ($LeeMeadowSong);

OR

2. Pay on the workshop day via Venmo, CashApp, cash, or check.
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Is there anything else you would like me to know? (This could include other important identity information you would like me to know; hopes or concerns you have for your reading; etc.)
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Client Acknowledgment and Disclaimer* This field is required.NATURE AND SCOPE OF SERVICES I understand that astrology readings and mythic guidework are intended for personal reflection, self-exploration, and the subjective consideration of life experiences, patterns, possibilities, and choices. These services may incorporate astrological symbolism, mythology, archetypal perspectives, and reflective conversation. These services are not a substitute for professional medical care, mental health care, psychotherapy, financial planning, investment advice, legal advice, or other services provided by appropriately licensed or qualified professionals. Nor are these services meant to be concretely predictive or descriptive of past or future events; the outcomes of any decision made by the client or another; the thoughts and attitudes of any individual or group of people; or the location of lost or stolen property. PROFESSIONAL QUALIFICATIONS AND LIMITATIONS I understand that Lee Saville-Iksic and MeadowSong Music and Soulwork are not acting as a licensed physician, mental health professional, psychotherapist, financial advisor, investment advisor, attorney, or other licensed professional by providing these services, unless expressly stated otherwise. Although a reading or consultation may touch upon subjects such as physical or mental health, relationships, employment, finances, or other significant life decisions, any discussion of these subjects is for reflective and educational purposes only. No diagnosis, treatment, financial plan, investment recommendation, or legal opinion is being provided. RESPONSIBILITY FOR DECISIONS I understand that any interpretations, observations, or perspectives offered during a reading are not guarantees of future events or outcomes. I acknowledge that I am responsible for evaluating the information discussed and for making my own decisions. I agree to consult an appropriately licensed or qualified professional before making decisions concerning my physical or mental health, finances, investments, legal matters, or other issues requiring specialized professional advice. I will not disregard professional advice or delay seeking appropriate care on the basis of a reading or consultation. NO GUARANTEES OF OUTCOMES I understand that astrology readings and mythic guidework cannot guarantee particular outcomes, resolve every uncertainty, or determine what decisions I should make. I acknowledge that these services are intended to support reflection and discernment, and that my experience and conclusions may differ from those of the practitioner. ACKNOWLEDGEMENT AND CONSENT By proceeding with a reading or consultation, I acknowledge that I have read and understood this statement, have had the opportunity to ask questions, and voluntarily consent to receive the services described above. I understand that this acknowledgment does not waive any rights that cannot lawfully be waived.
I have read, understand, and agree to the Client Acknowledgement and Disclaimer.
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