Printable Client Questionnaire

Full Name: ___________________________________________________________________

Birth Data
Date: _________ Month: _________________ Year: ___________________

Birth Place
City: __________ State: _________________ Country: __________________

Birth Time: ___________ AM: __ PM: __ (from Birth Certificate or other reliable records)

Formal Education:  ___________________________________________________________

__________________________________________________________________________

Training in Arts or Science: _____________________________________________________

__________________________________________________________________________

Religious and Spiritual Training: _________________________________________________

__________________________________________________________________________

Hobbies or Special Interests: ___________________________________________________

__________________________________________________________________________


Personal Data: Marriage(s) and/or Primary Relationship(s) Dates, etc. ___________________

__________________________________________________________________________
 

Birth Dates and Gender of Children: _____________________________________________

__________________________________________________________________________


Employment History (dates jobs began and ended; description of responsibilities): _________

___________________________________________________________________________
 

What is the most important thing you want the reading to help you achieve? ______________

___________________________________________________________________________
 

PLEASE READ, INITIAL AND SUBMIT TO COMPLETE YOUR ORDER

I hereby request you to inform me concerning the planetary forces active on the date of my birth and at other times during my life, as they are mapped by the Natal/Progressed Positions and Aspects of Scientific Hermetic Astrology. I affirm that my birth data, and whatever other information I supply on the Questionnaire, is accurate to the best of my knowledge.

In furnishing me this Astrological information, I understand that you obtain it from charts accurately computer-calculated using the Astrodyne method. I also understand that the Reading is NOT a computer-generated report, but rather an expert professional consultation personally recorded by you on audio cassette tapes.

I also understand that I am not asking you to "tell my fortune" in any sense, nor do I understand that you attempt or claim to do so. Instead, I realize that you will furnish me with thorough insight and understanding which, if I choose to act upon it, will enable me to have more complete self-knowledge and thereby improve my life experience.

Sincerely,

Name: _______________________________________________  Date: _______________

Address: __________________________________________________________________

City: ______________________________  State: __________  Country: _______________

Phone: ______________________________  Email: ________________________________
 

Please print, complete and either attach in an e-mail to: DRRUSSD@COX.NET

or

Please print, complete and mail to:

Rev Dr. Russ Durocher
P.O. BOX 86850
PHOENIX, AZ 85080-6850