Human Design Intake Form If you are human, leave this field blank. Confidential Client Information Date Full Name I like to be called Nickname or name pronunciation tips go here. Mailing Address Your Current Time Zone Email Address I will be sending your reading and all communication to this address. Skype Name Phone Number Who can I thank for referring you? May I add you to my mailing list? Yes, please. No, thanks. Birth Information Birth Date Month, day, and year. Birth Time Record hour and minutes. Note am or pm below. Birth Time am pm Birth Location City Birth State/Province Birth Country Birth Information Details: If you do not have access to a birth certificate or recorded birth time, share as many details as you can about your estimated birth time above. For example: Were you born in the early morning or at night? Was it close to sunrise or sunset? Any other distinguishing information? If there is a large discrepancy in charts during your estimated birth window, I may want to ask you further questions to rectify your birth time. Diving Deeper Questions These questions help me hone in on specific themes and foci for your reading. I encourage you to let me in to your world by revealing yourself. Why would you like a reading at this time? If you could wave a magic wand and solve one mystery about yourself, what would that be? What do you love about being YOU? List the areas where you judge yourself and think you should be _____________. This may sound strange, but your self-judgment is a powerful entry point for me as a reader. It can help me unlock golden nuggets for you. An easy starting point is completing the blanks: "I should be more/less __________." Go hog wild! Let me know about significant changes and transitions going on in your life, health, work and relationships: List behavior patterns or habits which you find confusing or you'd like to change in yourself: What is the number one focus/desire/priority in your life at this time? And how are you relating to it? Anything else you'd like me to know before I do your reading? THANK YOU!