New Client Intake Form
Designed for you to get the most out of your experience.
Name
First Name
Last Name
Email
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Phone Number
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Format: (000) 000-0000.
Date of Birth
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Month
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Day
Year
Date
Exact Time of Birth (include AM or PM)
Place of Birth (Township and Country)
What religious or spiritual beliefs do you feel most connected with?
Animism (Indigenous World View)
Paganism
Sufism or Mysticism
Christianity
Buddhism
Taoism
Non religious Spirituality
Atheism
Other
Are you actively practicing in your religion? (e.g. attending church/ceremonies, reading scriptures, following precepts, listening to sermons/dharma talks, etc)
What draws you to getting an astrology reading at this point in your life?
What are your main objectives and desires for working with Luna?
Understanding my karma and healing old wounds/mental patterns
Clarity and direction moving through a transitional time
Working on a specific issue (relationships/career/finance/health)
Spiritual growth and personal development
Other
Are you currently dealing with any mental or physical health challenges? Select all that apply.
Depression
Anxiety (nervous tension, restlessness, worry, insomnia, panic attacks)
Chronic Disease
Autoimmune Disease
Cancer
Physical Injury
Arthritis, Joint Pain
Digestive Issues
Low energy, fatigue
Other
If you answered yes to any of the above, can you identify when this began or when you first started noticing symptoms?
Are you currently working with a therapist, specialist or mentor to help you with a particular mental or physical health concern? If so, for how long and what progress, if any, has been made?
Are you currently taking any substances or medications? (including alcohol, cannabis, tabacco, prescribed medication). Please List.
What situations are you most likely to feel stressed out or triggered by? To be more specific, or if none apply, select other.
A. Feeling ignored, dismissed or rejected (e.g., being talked over, not receiving a response, feeling brushed aside or the idea that you're too much)
B. Feeling judged or criticized(e.g., sensing disapproval, fearing blame and accusation, feeling like I'm falling short of my true potential)
C. Perceived unfairness or bias(e.g., favoritism, unequal treatment, social or workplace inequities)
D. Feeling misunderstood, unseen or inadequate (e.g., others misinterpreting you, feeling invisible or unacknowledged, self comparison with peer success, performance expectations)
E. Loss of control, difficulty in setting boundaries, overwhelm (e.g., plans changing, feeling pressured or forced into something, feeling intruded upon, or unable to set limits that support self-regulation)
G. Conflict or tension (e.g., disagreements, confrontation, emotional friction, replaying arguments in the mind, feeling strong urgency to resolve matters)
Other
What do you find yourself complaining or worried about the most? Try to be honest and its okay to be petty!
Reflecting upon your life, what events or circumstances have left a mark on your psyche? These may be situations that are more sentimental in nature to significant calamities or upheavals. Please list any defining moments that come to mind without going into descriptive detail.
How do you normally react or deal with triggering situations?
I notice that I tend to comfort myself with food, substances, sex or seeking out validation from friends. I can indulge in my emotions and can get attached, clingy and become obsessive. People may experience me as needy.
I notice that I can become judgemental, arrogant or critical of myself and others. I may hold grudges, be more withdrawn and unable to feel compassion. I may expect people to come to me and at the same time I push them away. People may experience me as intimidating.
I notice that I can disconnect from my feelings and can become aloof, vacant or "spaced out". It's as if I mentally check out from the situation because I don't anticipate there being a positive outcome. People may experience me as distant or not available.
Other
What habits, practices, activities, resources, or people do you consider most beneficial and worthy of your time and energy right now?
What personal qualities, tendencies or skills do you see as worthwhile cultivating further?
What are your goals or hopes for 2026?
Clearly state your core intention for your session in one sentence.
Are you open to receiving a monthly newsletter, written to inspire connection, personal growth and healing? (you can cancel anytime!)
Sure, sounds good!
I'll pass, thanks
How did you hear about Luna Feyth?
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