INTAKE FORM name * First Name Last Name email * phone (###) ### #### date of birth * MM DD YYYY exact place and time of birth (if you're interested in birth chart information) home address (for receipt purposes) pronouns how did you hear about my services? do you know your sun, moon, and rising astrological signs? which of the following apply to your current situation? personal healing crisis spiritual awakening anxiety/depression stress/burnout relationship challenges wanting to know self deeper unprocessed trauma grief/loss other please specify, if other what are some of your hobbies/passions? what's your current profession/craft/art? do you identify with any national/ethnic/cultural groups? please share, if comfortable. are you currently taking any medical/psychotropic/recreational drugs? have you ever experienced abuse, neglect, or trauma? yes no maybe i don't know have you ever experienced the loss or death of a loved one? if yes, who and when? are you currently in a romantic partnership(s)? if yes, for how long? is your sexual orientation/gender expression something you would like to address in therapy? yes no maybe i don't know what are some of your strengths? (physical/psychological/emotional/etc) what are some of your shortcomings or areas needing improvement? (physical/psychological/emotional/etc) what's your understanding of spirituality and what role does it play in your life, if any at all? what brings you to seek therapy at this time? (i.e. triggering events/feelings/symptoms) if you had a magic wand, what would you wish your life to look and feel like? (i.e. goals/desires/wishes) thank you for taking the time to fill out this questionnaire! your input will provide us with a roadmap and a sense of direction in our journey together. looking forward to our first session! much love,constanza🌹