Your full name
	Email
	Address
	Postcode
	Telephone number
	Mobile number
	Occupation
	Place of Birth
	Date of Birth
	Please list the people who live with you
	Name Relationship Age
	What are your reasons for considering an Energy Alignment of your space at this time? What are you hoping to achieve?
	The Space Clearing aspect of our work aims to do two things: firstly to clean and clear out the stagnant energy that has collected over a period of time and secondly to fill the clean empty space with the kind of energy you would like for your home. On the day of the Space Clearing we will be cleansing, balancing and optimising the various energy fields in your environment on a variety of levels. Before we do this you will need to spend some time getting clear about what sort of energy you want to fill your home with. This is your ‘Intention’ for your home. You need to clearly define your Intention for your home. This is an essential first step to creating the kind of home you want e.g. do you want your home to be conducive to creativity, to be abundant and prosperous, to be full of family and friends or to be a quiet retreat?
	Where Intention goes, energy flows!
	My overall Intention for my home is:
	To aid us in our research please take a moment to observe the current condition of your environment, your health, and your relationships prior to our doing a clearing. You may wish to keep a copy of this for your own records.
	1. Plant Life Please note the condition of the plant life in and around the property to be cleared (please mark these from 1 to 10, with 1 being the poorest):
	Robust, Healthy	Please choose one 1 2 3 4 5 6 7 8 9 10
	Deep green colour	Please choose one 1 2 3 4 5 6 7 8 9 10
	Full, leafy	Please choose one 1 2 3 4 5 6 7 8 9 10
	Sparse leaves, holes in growth	Please choose one 1 2 3 4 5 6 7 8 9 10
	Brown or yellow leaves	Please choose one 1 2 3 4 5 6 7 8 9 10
	Twisted or distorted growth	Please choose one 1 2 3 4 5 6 7 8 9 10
	Fungus or disease on plants	Please choose one 1 2 3 4 5 6 7 8 9 10
	2. Animal Behaviour
	Nervous activity in animals and/or pets?	Yes No
	Barking dogs, inability to be still?	Yes No
	Are there birds singing in the area?	Yes No
	Pests present (ants, wasps, rats)?	Yes No
	3. Health Disorders Please tick if any of the following apply to those residing in the property to be cleared.
	Eating/digestive problems
	Inability to sleep
	Headaches
	Fatigue
	Nausea
	Skin rashes
	Aches and pains in joints
	Inability to hold focus or concentrate
	Depression
	Feeling of heaviness
	Shortness of breath
	Pain/constriction in heart
	4. Personal relationships Please indicate if any of the following are true in the environment to be cleared
	Poor communication
	Lack of cooperation
	Bickering or fighting
	Irritability
	Hostility
	5. Finances Please rate the flow of finances in your environment
	Steady, even, smooth flow
	Intermittent flow with some interruptions
	Blocked flow with obstacles and difficulties
	OTHER: Please list any other notable situations in your environment which you feel may be affected by some form of energy disturbance.
	I would like:
	Option I – Distant Work only
	Option II - Feng Shui Consultation including Distant Work
	Option III - On site Space Clearing Ceremony
	Option IV - Feng Shui Consultation from a floor plan only
	This option offers the client the opportunity to have a rudimentary analysis from the floor plan only. Recommendations can be made from observation of the house shape and compass orientation (if accurate readings are provided by the client).
	* Option - On site Space Clearing Ceremony and Feng Shui Consultation
	Whichever ‘Option’ you choose, we well need a hand drawn plan of your home incorporating any garden, (this does not have to be drawn to scale), giving us an indication of the size and layout of the rooms in proportion to one another. Please indicate this on the plan and either email us a copy or post it to: Energy Alignment, Studio 3, The Fold, Bransford, Worcs WR5 4JB front and back doors or those used most regularly location of bathroom(s),toilet(s), sink(s) and cooker windows and internal doors positioning of beds an A-Z map, ordnance survey map or similar showing where your property is located (this is helpful but not essential).
	Please give a brief history of your property and any specific problems you may have been encountering since moving in that prompted you to contact us: