____EVALUATION FORM____________

Please print out this page and than answer the questions. When the form is complete fax it to 518-514-1253. I will evaluate your needs based upon your answers and provide you with the appropriate Feng Shui Solution.

1. List all individuals living in your home along with their birth dates and their hobbies.

2. Does anyone in your family ill or have trouble sleeping?
(circle one) yes no

3. How long have you lived in your present home or worked in your present office?

4. If this evaluation is for a business what type of business do you have?

5. What do you know about the landlord or previous tenants?

6. Where in your home/office is your hobbie space, bedrooms, bathrooms, child's rooms or office space?

7. In the space below draw a simple outline of your home or office including windows and doors, include directions (north, south, east, west). Denote streets which surround your home or office. Include how busy or inactive the street noise is.