Celestial Vibrations L.L.C. Information Form Please provide the following information: Today's Date: M/D/Y Name: First Last Address: Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code Phone: (Please include your area code.) Email: (Please enter your BEST email address.) Best days/times to reach you: Ex: Mon. 10:00 am - 2:00 pm; Thurs. 4:00 - 6:00 pm Birthday and time if you know it: Date HH MM AM PM (M/D/Y) Are you married, divorced, committed, dating, single? Married Divorced Widowed Committed Dating Single (Please check all that apply.) Do you have children? Yes No If so, please list each child’s gender and age: Ex: Son 23, Daughter 18 Do you have any pets? Yes No Are you employed now? Yes No Are you self employed? Yes No If so, what do you do? What is your primary reason for having this appointment? Overall Happiness On a scale of 1-5 with 1 being very unhappy and 5 being very happy: How are happy are you with your life? 1 2 3 4 5 How happy are you with your career path? 1 2 3 4 5 How happy are you with your health? 1 2 3 4 5 If you are in a significant relationship, how happy are you in your relationship? 1 2 3 4 5 How happy are you with your spiritual life? 1 2 3 4 5 Where is your life falling short of your heart felt desires? Wellness (Please be as detailed as possible) Please describe your general condition of health: Describe any serious illnesses, injuries, and/or surgeries: Describe any persistent feelings of sadness, guilt, anger, depression, and/or anxiety: Are you currently under the care of a doctor? Yes No If so, list medications and reason for taking them: List dietary supplements: Are you in physical pain? Yes No If so, where? How intense is the pain? List: Light, Moderate, Intense, or a combination How often do you experience this pain? Ex: Occasionally, daily, weekly, monthly, etc... What do you do for relaxation? Ex: Read, bike rides, hike, swim, spend time with friends and family, etc... Is there any other information that you feel is important or would like to share? Thank you for your time and candor. We respect your privacy. Security measures have been taken.