Request For Specific Issue Astrological Consultation

First Name   Middle Initial
Last Name
Street Address 
City , State Zip Code
E-mail Address
Phone -- Ext.
Birth Date & Year
Birth Place City , State  
Country (If born outside USA.)
Birth Time am pm
Source of Birth Time (i.e., birth certificate, etc.)
Present Career
Marital Status
# of Children

Please provide a brief explanation of the issue you'd like to discuss:

Indicate the town you were in on your most recent birthday, as well as the day prior to and after your birthday.

Indicate the time of day and those days best to schedule an uninterrupted session.
Credit Card Information: MasterCard / Visa
Card #: 
Expiration Date:   

Please print your completed form and submit with check, money order or credit card information to the address or fax number below:

Cindy L. Suess

5422 Hermitage Ave., #101

Valley Village, CA 91607

Fax #:  (267) 295-2690

 

You can reach me with questions at (818) 760-7307 or email me at Cindy@depthastrology.com.  It takes approximately 1 week after receiving your data before I contact you to schedule your session.