The Astrology of Love & Relationships(Certificate Course)Student Intake Form Name * First Name Last Name Email * Current Address (Note: This information is required for tax reporting purposes.) * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Date of Birth (Note: This information is for instructor viewing only; birth information will NOT be shared without your consent.) * MM DD YYYY Time of Birth AND Time Zone * Place of birth (city, state/province, country) * Why did you sign up for this course? What interests you about it? What do you hope to get out of it? * How many years have you been studying astrology? * 0-5 years 6-10 years 11-15 years 16-20 years 21-25 years 26-30 years 30+ years Please list the teachers with whom you've studied astrology. If self-taught, please list some of the most impactful books you've read or self-study courses you've taken. * Are you a practicing astrologer who charges for services? * Yes No If yes, are you practicing full-time or part-time? * Full-time Part-time N/A - I'm not a practicing astrologer. How many years have you been a practicing astrologer? * 0-5 years 6-10 years 11-15 years 16-20 years 21-25 years 26-30 years 30+ years N/A - I'm not a practicing astrologer. Have you had any training in counseling or consulting skills? If yes, please describe. * Do you have training as a therapist or certified counselor? If yes, please describe. * Have you had ethics training related to the practice of astrology? If yes, please describe. * Please list any astology certifications you have earned. If none, indicate your response as "N/A." * Thank you for your submission! We look forward to having you as a student in our course!