Astrology Information Form

In order to receive accurate information from an astrological chart, I must have the following information. You can generally find this information on your birth certificate. If you do not have a copy of you birth certificate, you can obtain one from the county clerk in the county where you were born. Please make sure that you ask for a “detailed” copy of your birth certificate. If you cannot obtain this information, just fill out all that you can.

    Current Information

    Name (required)

    Address (required)

    City (required)

    State (required)

    Zip (required)

    Telephone (required)

    Email (required)

    Birth Information

    Full Name At Birth (first, middle & last) (required)

    Date of Birth (mm/dd/yyyy) (required)

    Time of Birth

    AM or PM

    Place of Birth ( City, State & Country if outside the US )

    City & State Where You Spent Your Last Birthday

    City & State Where You Will Spend Your Next Birthday

    Birth Time Source

    If your session is to take place by telephone:

    Once we have scheduled an appointment, you will be sent an invoice via e-mail with instructions on how to pay according to the payment type you have chosen below.

    Payment Type

    Pay with your credit card or debit card: We accept payments through PayPal. This safe and secure service allows our clients to pay instantly online using their credit cards, debit cards, or e-checks. The process is easy and safe, and you are not required to register with PayPal in order to complete this transaction.

    If you would like to send a check or money order by mail, a mailing address will be sent by email after I've received this form. Payment should arrive at least 1 week before appointment date.

    What are the main areas or issues of life that you would like to explore?

    Other Questions or Comments?