Scheduling and Payment Form
Fredericka Fairchild MA, Healing Arts LLC

FrederickaFairchild.com
Email: FFairchild@optonline.net
Mailing Address: PO Box 651, Shelter Island, NY 11964
Inquiries, Scheduling, and Fax: 631 749 1532

Please fill in the following information and submit. Upon PayPal receipt you will be emailed to schedule a convenient appointment. (Or, you may fax the office with a Visa/Master Card number, including Expiration date).  With either method of payment, be sure to submit form.  10-Business Days  cancellation or re-scheduling notice is required.
 
Your Name:


Mailing Address:


City State Zip Code Country:

 
Confirmed Billing Address if different from mailing address: (necessary for credit card payments and Paypal.com)


Email Address:

Day Time Telephone Number Including Work:

 
Fax Number: (to send directions for office visits)


Month, Day, Year of Birth

Time of Birth:   (leave blank if unknown)

AM
PM

Location of Birth: (Nearest large town, include State and Country)


Gender: (male or female)


Marital Status: (Single, Married, Widowed, Divorced)

Children:
 
Profession:

Who made this referral: (leave blank if non-applicable)

 
Please select the Healing Art you would like to schedule:
Astrology Life Path Readings:
Life Path Reading $275.00
Current Cycle Life Path Follow up Sessions $250.00
Synastry Comparison Charts $350.00
Numerology Life Path Readings:
Individual Name and or Business Analysis  $200.00
Corporate Identity  & Employee Numerology Analysis  $500.00
Transformation Counseling:
Weekly Counseling Session $125.00
Bi-Montly or every Three Weeks; $135.00
Once a Month Counseling Session $150.00
Sporadic Counseling Session  $200.00
Elixir Consultation:
½ Hour Elixir Consultation  $50.00
Hour Elixir Consultation  $95.00

 
Question/Special Concerns: (Include any medical condition, relationship, career or important issues)

 
Healing Arts are available in the Shelter Island office or by Telephone, EST on
Mondays-Thursdays from 7:30 AM – 3:00 PM
Please indicate dates and times over the 3 weeks you will be available for a consult:


Where would you like your session:
Shelter Island Office Visit
Telephone Consult (at the time of your session please call 631 749 1532)

 
Once you submit this form, you will be redirected to a payment page. Please note which services you indicated so you can pay appropriately.