Sunflower Moonrose LLC Intake Form

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Nastassia Johnson

Tarot Reader, Licensed Esthetician, Energy Worker

Sunflower Moonrose LLC

1 Hour Intuitive New Year's reading: $70

Email *

Name

Phone Number

Birthdate

YYYY

Sex

Male

Female

Prefer not to say

Other

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Pronouns

Clients should abstain from nonprescription drugs and alcohol before and after a session. Drugs and alcohol reduce my ability to connect with you during a session.

I understand

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Referred by

Have you had a shamanic journey or tarot reading before?

Yes

Not Sure

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What is your question for todays reading?

Is there anything else you would like me to know?

What are your skincare goals?

What skincare products are you currently useing?

Would you like any chat outside of the intuitive reading portion of the session?

No, only share intuitive messages after the initial skin analysis.

Yes, I'm a chatty Cathy and don't mind talking throughout the session.

I may fall asleep, please share the details towards the end of the session.

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Do you require an extra pillow under your back or legs?

Have you used Accutane in the past 12 months?

yes

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Are you using retinol or prescription tretinoin?

Have you had any hair removal services on your face over the past 3 days? (wax, sugaring, electrolysis, laser hair removal, threading) *Please hold off on any hair removal services before your facial appointment.

Have you had any of these cosmetic procedures in the past two weeks? *cosmetic laser, chemical peel, micro needling, Botox, filler, radio frequency

Have you had microdermabrasion, dermaplane or any other facials in the past 3 days?

Are you interested in product recommendations?

yes

No, not right now.

Maybe

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To ensure I meet your needs financially, what is your budget for products?

cost effective-I'm prepping for the holidays

Reasonable investment

Skin Splurge, I want to spend whatever I want right now as a Christmas present to myself.

I don't need any product recommendations at this time.

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What temperature would you prefer? (I have a table warmer)

toasty warm

cool

Not to hot not to cool, just right and cozy

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Are you open to me referring you to other practitioners I may feel you can benefit from seeing?

Yes

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Please note that the messages from spirit are unique to each individual. A tarot reading is not a substitute for medical treatment or mental health counseling. It may complement
many types of therapy.

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Nastassia B Johnson is not a doctor, nor does she practice medicine. She does not diagnose or treat for a specific illness or injury nor does Nastassia B. Johnson prescribe or adjust medications. She is also not a mental health care professional.

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By signing this form, “I” ( this client) give my consent to a tarot reading. I acknowledge I have read and understand the information below.

I understand that Nastassia B. Johnson does not guarantee any specific outcome from any tarot readings I understand the session fee, cancellation policy and information outlined on this form.

I understand

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Discontinuation of any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional will be discussed with a licensed health professional. I understand that by discontinuing any such treatment or therapy I agree to hold Nastassia B. Johnson and Sunflower Moonrose LLC free from any liability, and I assume responsibility for any negative outcome resulting from discontinuing any prescribed, ordered or recommended treatment or therapy.

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Nastassia will send an email overview of todays session within 24 hours.

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Full Name

Date

YYYY

I'm looking forward to working with you. :)

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