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Five Elements Report Intake Form

Please complete this form after your purchase so we can prepare your personalized Five Elements Life Direction Report.

Section 1: Order Information

Order number

Which report did you purchase?

Which report did you purchase?
A
B
C

Email used for purchase

Full name

Section 2: Birth Information

Birth date

Birth time

How accurate is your birth time?

How accurate is your birth time?
A
B
C
D

Birth city

Birth country

Current country / timezone

Section 3: Current Life Direction

What is your main reason for ordering this report?

Which area do you want the report to focus on most?

Which area do you want the report to focus on most?
A
B
C
D
E
F
G

What question would you most like this report to help you reflect on?

Are you currently facing a major transition?

Are you currently facing a major transition?
A
B
C

Section 4: Report Preference

Preferred report tone

Preferred report tone
A
B
C
D

Preferred language

Preferred language
A
B
C

Do you want more focus on practical action steps or self-reflection?

Do you want more focus on practical action steps or self-reflection?
A
B
C

Anything you do NOT want included in the report?

Section 5: Consent

I understand this report is for self-reflection and personal planning only. It is not medical, legal, financial, or psychological advice.

I understand this report is for self-reflection and personal planning only. It is not medical, legal, financial, or psychological advice.

I confirm that the information I provided is accurate to the best of my knowledge.

I confirm that the information I provided is accurate to the best of my knowledge.

I agree to receive my digital report by email.

I agree to receive my digital report by email.