Sunflower Moonrose LLC Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Nastassia Johnson

Shamanic Practitioner, Tarot Reader, Licensed Esthetician

Sunflower Moonrose LLC

Fee for 30 minute phone or zoom reading: $65

In-Person Sessions available upon request

Email *

Name

Phone Number

Birthdate

YYYY

Sex

Male

Female

Prefer not to say

Other

Clear selection

Pronouns

Age

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

Clear selection

Referred by

Have you had a tarot reading before?

Yes

Not Sure

Clear selection

What is your question for todays reading?

Is there anything else you would like me to know?

Are you comfortable with me pulling oracle cards also, if I feel called to do so?

Yes

Maybe

Clear selection

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

Yes

Other

Clear selection

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.

I understand

Clear selection

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.

I understand

Clear selection

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

Clear selection

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.

I understand

Clear selection

I understand I am responsible to give 48 hours cancellation notice or pay the fee in full $65. All purchases are non-refundable, non-extendable, and non-returnable. All sales are final.

I understand

Clear selection

Full Name

Date

YYYY

*Please allow up to 48 hours for an email reply for scheduling after submitting your form. I'm looking forward to working with you. :)

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.