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Worksheet

Initial Intake Questionnaire

Fill out in as much detail as you feel comfortable sharing and we will discuss further in your upcoming session.

1. ➜

First Name

2. ➜

Last Name

3. ➜

E-mail Address

4. ➜

Phone Number

5. ➜

Birthdate, Place of Birth, Time of Birth

For medical astrology purposes.

6. ➜

If you purchased an astrology reading, which asteroid do you want me to read?

7. ➜

What is your occupation?

8. ➜

What are your key health challenges and main concern right now?

9. ➜

What are you trying to do right now to change this (diet, lifestyle and supplement wise)?

10. ➜

What have you tried to do to solve your health challenge in the past that didn't work?

11. ➜

Is there anything that you've done in the past that helped, but you aren't doing anymore? Why?

12. ➜

Is there something that worked in the past, but doesn't seem to be working anymore?

13. ➜

What from your perspective do you think is at the root cause(s) of your issue?

14. ➜

What in particular is motivating you to do what it takes to reach out to get support now?

15. ➜

Why is overcoming your issue a priority now?

16. ➜

Which of the following apply:

17. ➜

Please list all diagnoses (past and present), plus any surgeries you've had:

18. ➜

Please list all medications that you take (including dose and frequency):

19. ➜

Please list all supplements that you take (including dose and frequency):

20. ➜

Anything else you would like me to know?

I look very forward to seeing you in your upcoming session!

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