Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Birth Time *

Hour

Minute

Second

AM PM

Diagnosed with: *

Check all that apply

Attention Deficit/Hyperactivity Disorder (ADHD)

Autism Spectrum Disorder

Bipolar Disorder

Boderline Personality Disorder (BPD)

Depression

Eating Disorder

Generalized Anxiety Disorder

Obsessive-Compulsive Disorder (OCD)

Schizophrenia

PMDD

Post-Traumatic Stress Disorder (PTSD)

Complex PTSD (C-PTSD)

Other

Disclaimer *

Disclaimer: Confidentiality and Purpose of Study This form is part of an astrological research study exploring potential correlations between birth chart patterns and experiences of mental illness. Participation is entirely voluntary. All personal and identifiable information collected through this form will remain strictly confidential and will not be shared, published, or distributed. Data will be used solely for research purposes and analyzed in a way that ensures anonymity. This study does not provide medical advice, diagnosis, or treatment, and participation should not be considered a substitute for professional mental health care. If you are experiencing emotional distress or mental health challenges, please consult a qualified healthcare provider. By submitting this form, you acknowledge that you understand the purpose of this study and consent to the use of your responses in anonymous, aggregate analysis.

I agree