Intake Form

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Client Intake Information

* Indicates required field

Reading Purchased *

One on One Blueprint Reading Recorded Blueprint Reading One on One Intuitive Reading Recorded Intuitive Reading Child Reading

Current Name (First and Last) *

First

Last

Email *

Phone Number *

Skype Concact (if needed) *

If you need to use Skype please enter in your Skype contact

Scheduling Information For One on One Readings:

Current Time Zone *

Please let me know what your current time zone is (ie PST,MDT,CMT, EST etc)

Best Scheduling Times *

Mornings (8am to 11am) Mid Day (12pm to 2pm) Late Afternoon (3pm to 5pm) Evening (6pm to 9pm)

Please let me know which times of day work best to schedule your reading.

Chart Information:

Full Birth Name *

Please send me your fill birth name (ie birth certificate name).

Place of Birth *

Please list the city, state and country you were born in. If you are unsure please state that you do not know.

Date of Birth *

Please send me the month, day and year you were born

Time of Birth *

Please list your time of birth. If you are unsure of the exact time put in your best estimate

Is this the exact time of birth? *

Yes No

Were you Adopted? *

If you were adopted and had a name change at birth please list what you know. This is not required information, but can be extremely helpful to work into the chart.

Specific Questions? *

Do you have any specific questions or comments?

Submit

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Home
About Amy
Readings
Testimonials
Officiant
Contact & Feedback