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Residential Consultation Questionaire and Request

This questionnaire is long. If you prefer to give this information to Donna by phone please call 800-918-2689.

About You	* = required field
First name *
Last name *
Address *
City *
State/Province *
Zip/Postal code *
Day phone *
Evening phone
Email *

Date of birth *
Time of birth (if known)
City of birth

Your profession

Other people Living in the home
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you (example: Adult student who lives in your home for the summer would be three months a year or 25%)
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you
Name
Relationship to you
Their profession
Date of birth *
Time of birth (if known)
Amount of time or percentage of the year that they live with you
Your pets (the energy of pets is very positive for a home, but large numbers of pets can shift the energy)
Pet's name
Type of pet

Pet's name
Type of pet

Pet's name
Type of pet

Pet's name
Type of pet

About your home
Type of dwelling (single family, condo, mobile home, etc)
Date the home was built (if known)
Month and year you moved into the home
How long do you want to stay in the home?
Is the home currently for sale?
If so how long has it been listed
Square footage of the home or number of rooms

Special Circumstances
Please explain any special circumstances that may
affect the energy of the house (such as you rent a single room in a larger house or your mother-in-law rents the unit above you or you use the house only during the summer, etc.)

About your experience in the home
Have you, the people or the pets who live with you experienced health problems since living in the house?

Have you or anyone living with you experienced financial set backs since living in the house?

Have you or anyone living with you experienced emotional loss since living in the house?

What would you like to change in your life?

What would other people who live in the house like to change in their lives?

To what extent are you willing or able to make changes to the home (example: are you willing to paint, just willing to do minor changes, need changes that are practically invisible, you are willing to rip down walls, etc.)?

Can your provide a floor plan (required for consultations via phone)?
(a floor plan can consist of hand-drawn outline of rooms, draw in large pieces of furniture such as beds, desks, tables and sofas, mark TV and computers, mark doors and windows, if possible list compass directions.)

Can you provide pictures (required for consultations via phone)?
Photos should include:
The front door when looking in—view of the entry/foyer
The front door looking out—view of walkway, houses across the street
Alternate entrance looking in—view of the room you enter
Alternate entrance looking out—view of porch or garage
Living room from the main entrance to living room
Kitchen from the door into kitchen
Bedrooms from the door
Baths from the door
Home Office from the door
And if you have additional rooms or rooms that you feel are important then a picture of those as well.
Large rooms should be photographed from several angles. Photos can be emailed to donna@fengshuiform.com

Other comments:

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