Intake Form for Astrological Health Reading

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 lasts approximately 60 minutes, depending on your questions and the complexity of your 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 feeling your best. 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 form helps ensure your reading is as personalized and meaningful as possible and must be completed before scheduling your reading.

Once submitted, you will be automatically directed to the booking page :)
A limited number of readings are available each month. Consultations are currently offered on Thursdays and Fridays at 10:30 AM and 1:00 PM Eastern Time.
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.
Preparation for your consultation begins shortly after your appointment is booked and typically requires 3–4 hours of dedicated chart analysis. Because this work is completed in advance, appointments cannot be cancelled once booked and are not eligible for a refund. If an emergency prevents you from attending, I am happy to move your appointment forward on one occasion. Beyond this, I am unable to accommodate repeated or short-notice rescheduling requests. Missed appointments (no-shows) are not eligible for rescheduling or refund.
Signature
(Type your name above)
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Astrological Health Reading ($350 CAD)

Health

Timeline

Lifestyle

Consultation Guidelines & Agreements

Rescheduling Policy