Client Intake Form

Name*

First NameLast Name

Preferred First Name*

Nickname

Age*

Date of Birth*

Date

Time of Birth*

Hour Minutes

AM/PM Option

Birth City, State/Province, County, and Country*

Detailed birth information allows me to analyze your human design and natal charts to craft a more personalized experience for you, focusing on strategies that will naturally align with you. If you do not have access to this information for any reason, simply type that in the field above.

Gender

FemaleMale

Phone Number

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Marital Status*

SingleMarriedDivorcedWidowed

Occupation

Are you currently taking any prescription medications?

YesNo

Do you have any health condition(s) that you would like to share?*

YesNo

If yes, then please share below:

Please provide background information you deem important in understanding your current situation and state of being (emotional, physical and/or mental). *

What inspired you to seek support now?*

What are your personal goals?

What are your professional goals?

What are your personal and professional strengths and assets?

What changes would you like to make in your life right now?*

What upsets you?

What brings you joy?

What is your motivation in life?

What are you committed to do to achieve your goals?*

What are your expectations from our exploration together?*

Would you like to receive updates, news, and promos?*

YesNo

How did you find out about our services?

Service Agreement:

By submitting this form, I understand that, in order to be successful, it is vital to participate actively in each session and follow any advice or plan agreed to by both the client and provider.

I understand that all services offered by A Soul Purpose are spiritual in nature and intended to support personal and energetic well-being. These services are not a substitute for medical, psychological, or other licensed healthcare. Each individual’s experience is unique, and results cannot be guaranteed. While many clients report meaningful insights or positive outcomes, there are no promises, warranties, or guarantees regarding results. As with any healing or wellness modality, experiences vary from person to person, and much depends on the effort the client brings to each session and the work they do between sessions.

I understand that this provider is not a medical doctor, psychologist, or licensed healthcare provider, and does not diagnose, prescribe, treat, or cure any medical or psychological condition. Clients are encouraged to continue receiving care from their licensed medical and mental health professionals. This work is designed to complement conventional medical and psychological treatments, not replace them.

I understand that all information I enter in this form will be considered strictly confidential. The data gathered from this form will only be used as a basis for the type of support the client may need.