Vedic Astrology Natal Chart Reading Intake Form Dear Friend, Please fill out the two pages called ‘before the appointment’ and send them to me right away. It is important to have the exact time of birth. Your session with me (and any information provided below) will be held in strict confidence. Be sure to be in a quite, serene place if your reading is by phone. You will receive a printout of your chart and an MP3 recording of the reading. Reading and Payment InformationFee: $250 Session Length: 60 minutes Please be punctual. Once on the calendar, a 48-hour notice is required to reschedule or cancel (otherwise a new payment will be required to schedule another reading). Required InformationFull Name* First Middle Last Cell Phone*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Day* Month Day Year Birth Time*(exact, from birth certificate) : HH MM AM PM AM/PM Birth City and State* City State / Province Birth County* Birth Country* How (from who) did you hear about me?* Marital/Partner Status? Prior divorce?* Kids (ages)?* While growing up, how was the relationship with Father? Mother? Siblings?*Occupation? Happy with career?*How would you describe your relationship with money?*How would you describe your health?*How would you describe your Spiritual Beliefs?*Have you had a reading before? If so, how was the experience?*Do you have a Key Question for your reading (not required)?Anything else you want me to know about you or your situation (not required)?Natal ReadingCoupon Fee $0.00 Payment Method*Please choose your payment method. E-check / Bank Transfer Credit Card online Pay by e-check Name on Account Bank Name Routing Number Account NumberCheckingSavingsAccount TypeCredit CardCard Details Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Δ