ONLINE FENG SHUI CONSULTATION QUESTIONNAIRE

This form is for those wishing to schedule a free consultation. 

If you just wish to Contact Me, please use the Contact Form. 

To help me prepare for our consultation, please fill out the following questionnaire emphasizing your key issues and concerns. Feel free to only fill in the information you are comfortable giving me.

All information is confidential.

* = Required
Personal Details (Page 1 of 6)
Name
First:  *   Last:  *
Address
Street: *
City: * State: *   Zip: *
Email address:	*
Confirm email address:	*
Home telephone:	*
Alternate number:
Occupation:
Relationship status:	-- Select -- Single Married Divorced Widowed Living with Partner
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * Year 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 *
Current Age:
Time of Birth:	Select 1-3m 3-5am 5-7am 7-9am 9-11am 11am-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm 11pm-1am unknown
Place of Birth
City: State: Country:
Best time to contact you:
Your best three dates for your free consultation:

Other Occupants (Page 2 of 6)
Partner or co-habitants name
First:  Last:
Relationship:
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Current Age:
Time of Birth:	Select 1-3m 3-5am 5-7am 7-9am 9-11am 11am-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm 11pm-1am unknown
Place of Birth
City: State: Country:
Number of children :
Number of occupants in home:

About Your Space (Page 3 of 6)
Space is:	-- Select -- Private House Town House Apartment Flat Cottage Studio Other
Number of bedrooms:
Approximate square footage:
What year did you move in?
Year the building was built:
Year(s) of major renovations:
Details of any major renovations:
Is a floor plan available?	Yes No
If yes, are you able to provide a copy?	Yes No (Kinko's have floor plan size copiers)

General Questions About Your Home (Page 4 of 6)
Are there any rooms that are not used?	Yes No
Do you work from home?	Yes No
What do you love about your home?
What do you dislike about your home?
Which rooms do you spend the most time in?
Are there any issues or disturbances adjacent to or around your property? Yes No   If yes please describe
Experiences since occupying your home
Career successes or tensions:
Auspicious events:
Significant accidents, injuries or health issues:
Significant births or deaths:
Other:

Your Personal Situation (Page 5 of 6)

Please tell us about the aspects of your life you'd like to work on by selecting the appropriate boxes.

Relationships

Relationships are not a problem for me right now

I am single and looking for marriage or a committed relationship

I am already in a relationship but need improvements in it

Want improved husband/wife or committed relationship

Suspicion of or trouble with extra marital affairs/ roaming eyes

Daughter/son relationship

Mother/father relationship

Any other relationship issues?

Career and Finance

Career and Finance is not a problem for me

I have trouble saving money

I have trouble and I'm not making enough money

I need to have better luck

I feel stuck in a dead end job

Looking for career change or advancement

Trouble at work

Business is not doing well

Any other career/finance related issues?

Health (please specify any conditions in the Additional Information area below)

My health is fine, no help needed here

I don't sleep well at night

I sleep well but wake up feeling exhausted

I need more energy, suffer from lack of energy

I feel down and need to feel more positive

Trouble getting pregnant / suffered miscarriage

Low Sex drive

Any other health related issues?

Focus Questions and Goals (Page 6 of 6)
You may choose to send this section back or print it for the on-sight consultation.
List 3 things in life that give you the most fulfillment
1.
2.
3.
List 3 short-term goals (1-3 months) using positive words or phrases
1.
2.
3.
List 3 long-term goals (to achieve in one year)
1.
2.
3.
What are you most passionate about in life?
Are you living out your passions?