Intake Form for Astrological Health 1:1 Private Consultation

Astrological Health Reading ($350 CAD)

A comprehensive analysis of your natal chart is completed prior to our session and typically requires 3–4 hours of preparation. The consultation itself is typically 30–60 minutes, depending on questions and the complexity of the chart.
These consultations are primarily focused on using astrology for health optimization and learning how to work with your natural constitution in ways that support you in both looking and feeling your best. However, if you are currently experiencing any health concerns, symptoms, diagnoses, or ongoing challenges, please provide details below so they can be thoughtfully considered within the context of your session.
All information submitted is kept completely confidential.
This intake helps me prepare for your consultation and understand how best to support you through your current health and life patterns. This form must be completed prior to scheduling your reading.

Once submitted, you will be automatically directed to the booking page.
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Exact Time of Birth

Hour Minutes

AM/PM Option
Location of Birth (include City & Country)
Health
Do you have any health concerns, medical diagnoses, conditions or symptoms?
(Please include both physical and emotional/mental experiences if relevant. Examples may include energy levels, digestion, sleep patterns, hormonal concerns, chronic conditions, or anything else impacting your well-being. If none, you may write “No current concerns or symptoms.”)
If relevant, what healing modalities have you explored so far in addressing your health concerns?
Please share what has been most helpful, what has had little effect, and anything that seemed to make things worse.
Timeline

This section is most relevant if you are seeking insight into specific symptoms or health concerns. If you are booking for general health optimization, you may leave it blank.
When did your main symptoms or health concerns begin?
Exact date (if known): _______

Approximate timeframe (if not): _______
Was there anything happening in your life around that time?
(major life events, stressors, transitions, emotional experiences, or trauma — if known or relevant)
Lifestyle

Whether you are working through symptoms or simply optimizing your health, this section helps me use your birth chart to identify patterns and areas that may benefit from additional support.
What does your current movement/exercise routine look like?
(If none, you can simply write “none” or “not currently active.”)
How would you describe your eating patterns and relationship with food?
Optional: appetite changes, cravings, restrictions, or dietary patterns
How is your sleep?
(e.g. difficulty falling asleep, staying asleep, waking refreshed, dreams, etc.)
How would you describe your typical energy levels throughout the day?
Is there anything else you would like me to know before our consultation?
Consultation Guidelines & Agreements
Privacy & Confidentiality
Accuracy of Information
Payment Policy & Fee Schedule
Rescheduling Policy

A minimum of 48 hours’ notice is required to reschedule your appointment.
Repeated short-notice changes or frequent rescheduling cannot be accommodated, as this affects availability for other clients.

In the case of an emergency, I understand that flexibility is sometimes required, and I am able to move your appointment forward one time if needed. Beyond this, I am unable to accommodate repeated short-notice changes or frequent rescheduling, as it affects my availability for other clients.

Missed appointments are not eligible for rescheduling or refund.

If an appointment cannot be attended after the one permitted reschedule has already been used, the live consultation will no longer be available.

In these cases, a written summary of the prepared analysis may be provided in place of the live session, as preparatory work will already have been completed.
Signature
(Type your name above)
Should be Empty:

Astrological Health Reading ($350 CAD)

All information submitted is kept completely confidential.

Health

Timeline

Lifestyle

Consultation Guidelines & Agreements

Rescheduling Policy