INTAKE FORM

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INTAKE FORM

DAYDREAMING @ Temple Of

Julia Arredondo + Chad Kouri on view April 28th - June 3rd, 2023 at Roots & Culture Chicago.

astrology, hypnosis, daydreaming, divination available:

Wed. May 10 + Sat. May 20 + Fri. June 2

To get the best out of your experience, please fill out this brief questionnaire at your earliest convenience. Ideally, at the time of booking or at least 12hrs before our visit.

PART 1 - About You

Email *

Same one you will use for our appointment.

Name *

Pronouns

They / Them

She / Her

He / Him

Other:

Your Birthday *

YYYY

Birthtime

We use this to cast your natal chart and is important for confirming your rising sign.

Time

How accurate is this time?

Please note, although we can pull your chart without a solid time, you will get the best results with an accurate hour and minute; So it's worth searching for it if you can.

What (city / state / country) were you born? *

Used to cast your natal chart.

PART 2 - About our session

Your session is on *

These private sessions means we have the whole gallery to ourselves.

**Public gallery hours are great for walk ups and short reads between 12-6pm on Friday.

Wed. May 10

Sat. May 20

Fri. June 2

**Fri. June 2 during public gallery hours

I need another option, let's coordinate over email!

What do you want to get our of this session?

The more details you provide, the better I can prepare ahead.

How will we spend out time together?

Astrology

Hypnosis

Divination

Platicas / problem solving

Limpias / energy cleansing

Are there any boundaries or triggers you'd like for us to be mindful of?

Only share what you feel comfortable, it can be surface level.

When you're doing you best, where and how do you feel it?

What comes to mind when you think of a peaceful place?

When you close your eyes to imagine something, how do you get information?

Seeing / in my minds eye

Hearing

Smelling

Feeling

Knowing

Other:

Please read and sign off on to the following

By submitting this intake form you understand the Terms & Agreements regarding hypnosis and the statements below:

Arrive on time to be respectful of fellow participants and gallery attendants

Let the facilitator know if you must cancel or are running late as soon as possible.

You can reschedule once at least 24hrs prior. Please note that in-person availability is very limited. Our session might be moved to zoom instead.

Pay the remaining amount at time of session via venmo, cashapp, zelle, or cash (no change).

Masks are encouraged but please stay home if you are feeling sick or have been exposed to others with illnesses.

Items you can bring to your hypnosis session: yoga mat, crystals, oils, eyemask, small pillow, blanket or scarf to cover yourself

Thanks so much-- See you at our session!

Roots & Culture is located at 1034 N Milwaukee Ave.

I'll meet you at the door during your appointment time.

Reach out via email for questions or help: info@kpfkpf.com

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