Qi Advisor Feng Shui


This form is for those wishing to schedule a consultation. 

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

All information is confidential.

* = Required
Personal Details (Page 1 of 4)
First:  *   Last:  *
Location Address
Street: *
City: * State: *   Zip: *
Email address: *
Confirm email address: *
Phone Number: *
Alternative Number:
Relationship status:
Date of Birth: * * *
Current Age:
Time of Birth: :  
Place of Birth  
City: State: Country:
Best time to contact you:
Other Occupants (Page 2 of 4)
Partner or co-habitants name
First:  Last: 
Date of Birth:
Current Age:
Time of Birth: :  
Place of Birth  
City: State: Country:
Number of children :
Number of occupants in home:
About Your Space (Page 3 of 4)
Space is:   
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 4)
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: