Residential/Energy Clearing Thank you for expressing interest in Classical Feng Shui Services and Momentum Feng Shui. Please complete as much of this initial intake form as possible to secure the date. This will enable me to provide the most fitting ways to enhance your space to be a nurturing environment that will help you reach your fullest potential.Questions about youFirst Name *Last Name *Email *Phone *0 / 13Date of birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Address *City *State/Province *ZIP / Postal Code *Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweOccupation *Questions about spouseName *Spouse's OccupationDate of birthMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you live with other people (not including you or spouse)? *YesNoPlease write their name, date of birth and gender (one per line). *What year was your Home built? *Do you have a copy of the (Architect) Floor Plan? *YesNoUpload any plans hereDrag and Drop (or) Choose FilesMax. file size: 16 MB.Please explain *What is the approximate S.F. of your living space (excluding rented suites if applicable)? *Has there been any major remodelling (adding rooms etc only) since the original construction? *Do you rent or own? For how long? *Do you know the Home's history? Did the previous occupants move on in a prosperous way? *Are you aware of any positive or negative things that may have happened in this Home over the year? *Since moving to this Home, have you noticed any changes in your life, positive or negative? *How do you feel when you step into your Home? Do your spirits rise or fall? *Do you find you have rooms you like more than others? *What is your overall Intention for your Home? What made you decide to have a Feng Shui Consultation? *On a scale of one to five with five being the most satisfied or content and one being the least satisfied or content, type the number that is appropriate for the area in question. Select NA if the question does not apply.1. Career and Life's JourneyAre you passionate about what you do for a living and does it feel fulfilling? *12345NAAre you acknowledged and respected by people you work around? *12345NA2. Knowledge / Wisdom / Self CultivationDo you feel free to grow & learn new things, and have adequate time & opportunity to nurture yourself? *12345NADoes your life and schedule allow time for cultivating new knowledge and awareness? *12345NA3. Family / CommunityDo you have a good relationship with your family that you live with or do you feel tension or an unusual amount of arguing within your family? *12345NADo you feel connected to a sense of community? *12345NA4. Wealth / Prosperity / AbundanceDo you feel fortunate in your life? *12345NAAre good things happening to you? *12345NADo you feel you spend money wisely…or does it seem to ‘disappear’? *12345NADo things show up when you need them without expectation? *12345NADoes your life feel abundant? *12345NA5. Fame and Reputation (how you shine your light in the world)Do you feel good about yourself and who you are? *12345NAAre you overly concerned about what people think about you? *12345NADo you feel you have gifts and wisdom, light to share with others? *12345NA6. Love and RelationshipsDo you find it easy to love yourself, and to care for your emotional, spiritual & physical needs? *12345NADo you find you are able to flow with your partner and work together on life’s everyday tasks or does communication between you and your partner seem strained most of the time? *12345NAIf you are single, do you seem to attract the ‘wrong type’…or find it difficult to meet single eligible people? *12345NA7. Creativity / Children / Inner ChildAre you creative and excited about life and starting new projects? *12345NAIf you are a parent, is your relationship with your children rich and positive? *12345NAIf you want kids, are you having trouble planning or conceiving? *12345NADo you feel connected to yourself and the playfulness within you? *12345NA8. Travel / Helpful PeopleDo you feel supported by friends and family? *12345NADoes it seem that the right people show up in your life at the right time…being ‘angels’ in some way? *12345NADo you travel as much as you would like? *12345NADoes it feel like you’re missing opportunities to see the world? *12345NA9. Health / Unity / BalanceDo you and your family enjoy good health? *12345NADoes your life feel in balance and do you eat well and exercise in keeping with your goals? *12345NAAfter reviewing these questions, (and talking with your partner, if you have one), please take a few minutes to explain any of these areas that don’t feel good to you right now. Maybe you feel they are blocked in some way, or there is something missing or hindering you from living and feeling your full potential. What would you like to change about how your life feels? *What areas (1-9) seem to need attention for improvement in your life? *During our time together we will be working with your personal space to nourish, replenish and empower Positive thoughts, Affirmations and Goals. Before our appointment, please spend some time clearing out any clutter you have accumulated. If it is not functional, get rid of it. The more thoroughly you do this, the better the results you will get in creating the energy you want for your Home. In Classical Feng Shui, remedies need to be renewed every year. An updated study is calculated in my office for nominal fee. The Clients are sent a simple floor plan marked with the remedies, to guide them on the placement for the upcoming year. Please provide a floor plan of the Home or draw one as close to scale as possible, labelling all rooms such as living room, kitchen, bedrooms etc. This is a very important part, to ensure the accuracy of placement of remedies. Please be as accurate as possible with the floor plan and compass directions. Please complete this form within 48 hours to secure our appointment date. 50% Deposit is required which can be sent in the form of an etransfer to info@momentumfengshui.com. Balance of payment is due at the conclusion of our final appointment. Please note: All information you provide will be held in the strictest of confidence. Services and consultations provided by Momentum Feng Shui are not intended as a substitute for the care of a licensed medical provider. I serve as a reference and guide for Feng Shui Services. There are no guaranteed outcomes, please keep in mind that individual results may vary, based on client interest and participation.Do you consent? *I agree.Please make a note of this email address and the total amount due with submission of this questionnaire.Your Initial *Please type your initial as proof of agreementEnergy Clearing plays an integral part in the outcome of achieving results in Feng Shui Consultations. If the Home has been preowned, or there have been life-altering experiences (i.e. sickness, sadness or death), or patterns of arguments and distress, the energy is absorbed and stored into walls, carpet and ceiling etc. It is important to have a Space Clearing, Cleansing and Rebalancing Ritual to reset the Energy so we can start with a clean slate and embed your Intentions using the Classical Feng Shui Cures. The 3-step Service includes: Zenergy Chimes: programmed with a very soothing voice command to lift the stagnant and stuck energy from walls, closets, basement, garage and any other unused areas of the Home. Smudging Ceremony: starting clockwise from the Front Foor with Sage to command the newly lifted heavy energy to leave the Home through open doors and windows on all levels of the Home. Rose Water: is sprinkled throughout the Home in the same direction while Reciting specific Mantras unique to the client’s needs and desires to seal in the positive energy and attract more of it. All Rituals above are performed with Intention while I guide my clients to sit in a peaceful space, move forward 6 months in their desired life and embed their own Intentions into the newly freed up space energetically while I focus on inviting the Energy of the 4 P’s: Protection, Productivity, Prosperity and Positive Vibes! Feng Shui Consultation starts at $888 + GST (up to 3500 S.F.) Energy Clearning when added onto the Feng Shui Service as a package is $288 (otherwise $488) Residential Feng Shui Consultation + Energy Clearing Service: $888+ $288 = $1,176 + GST = $1,234.8 50% Deposit $617.4 Please make payment via e-transfer to info@momentumfengshui.com Residential Feng Shui Consultation only $888 + GST = $932.4 50% Deposit $466.2 Please make payment via e-transfer to info@momentumfengshui.comWould you like to add on Energy Clearing Service to the Residential Feng Shui Consultation for an additional $288.Yes, please add on the Energy Clearing ServiceNo, thank youWill you be sending the required 50% deposit with this package?YesNoPlease provide reasonSignature *Please type your full name as proof of signature.The Undersigned and anyone claiming on Releasor’s behalf (the “Releasor”) hereby agrees to this Waiver of Release of Liability, Indemnity, and Assumption of Risk (the “Release”) and in consideration of payment for Feng Shui and Energy Clearing Services, which includes but is not limited to providing advice, clearing the home, providing remedies, and selling products (the “Services”) hereby release and forever discharge Meena Jagpal-Paré, Momentum Feng Shui, and its affiliates, successors and assignees, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, the “Releasees”), in their individual and/or corporate capacities from any and all causes of action known or unknown, which Releasor has, had, or may in the future have against any of the Releasees of and from any and all manner of actions (whether civil, criminal, administrative, investigative, or informal), causes of action, suits, arbitrations, audits, hearings, investigations, litigations, debts, accounts, due accounts, bonds, covenants, contracts, claims, demands, damages, costs, expenses, and any and all legal obligations and compensation of whatsoever kind and howsoever arising, in law or in equity, or under any statute, whether known or unknown, suspected or unsuspected (collectively, “Claims”), and which the Releasor has had, now has, or hereafter can, shall, or may have against the Releasees or any of them in respect of any matter or thing arising at or before the date hereof, and further agree that if, despite this Release, the Releasor, makes a claim against any of the Releasees, the Releasor will indemnify, save and hold harmless each of the Releasees from any litigation, expenses attorney fees, loss, liability, damage, or cost which any and all of them may incur as the result of such claim. The Releasor covenants and agrees not to, directly or indirectly, join, assist, aid, or act in concert in any manner whatsoever with any other person in the making of any Claims whatsoever against the Releasees with respect to the matters released or discharged pursuant to this Release or with respect to which the Releasor agrees not to make any Claims. The Releasor further covenants and agrees not to make or continue any Claims against any person that might be entitled to claim, pursuant to the provisions of any applicable statute or otherwise, a contribution, indemnity, or other relief over against the Releasees arising out of or in relation to the matters released or discharged pursuant to this Release. The Releasor hereby acknowledges and agrees (i) that the Services provided by the Releasee to the Releasor is not medical advice, or other forms of advice and does not in any manner or form substitute or override any medical advice, or other forms of advice; (ii) that the Releasee does not guarantee spirituality, health, success, or prosperity; (iii) the Releasor acknowledges and agrees that that the Services are used at the Releasor’s own discretion, choice, and risk (iv) the Releasor hereby assumes all risks including but not limited to social and economic losses and fully accepts and assumes all such risks and responsibility for any or all losses, injury, costs, and damages which may incur as a result of the Services; and (v) to the risks of exposure related to COVID-19 while meeting with the Releasor and acknowledges and agrees that the Releasor may need to be closer than the recommended social distancing guidelines if the Releasee is requested to meet with the Releasor in person. By signing this Release, the Releasor acknowledges and confirms acceptance and willingness to accept all risks related to the Services and as a condition of receiving the Services. This Release will ensure to the benefit of the Releasees, its heirs, executors, administrators and assigns and be binding upon the Releasor, its heirs, executors, administrators and assigns. The facts in respect of which this Release is made may prove to be other than or different from the facts now known by any of the Releasor or the Releasees or believed by any of them to be true. The Releasor expressly accepts and assumes the risk of the facts being different and agrees that all of the terms of this Release will be in all respects effective and not subject to termination or rescission by any discovery of any difference in facts. In the event that any provision of this Release, or part thereof, shall be found to be void or invalid by a court of competent jurisdiction, such void or invalid provision, or part thereof, shall be deemed to be severed from this Release without in any way affecting the validity, enforceability, or effect of any of the remaining provisions, or parts hereof, which shall remain in full force and effect. The Releasor acknowledges, agrees, and represents that they are of a lawful age and legally competent to sign and agree to this Release. The Releasor acknowledges and confirms that the Releasor has had the opportunity to seek independent legal advice with respect to this Release or has agreed to waive its right to seek independent legal advice, and that the Releasor fully understands this Release and the terms set forth herein. The laws of the province of British Columbia will govern this Release. It is expressly understood and agreed that the provisions hereof are contractual, and are not merely recitals, and will be binding upon the Releasor. Any personal information collected will be used for retraining the Services. The personal information provided will be used and disclosed only for the purpose(s) for which it is collected, unless consented to otherwise, or we are authorized to do so under The Freedom of Information and Protection of Privacy Act (FIPPA).Do you consent? *I agree.Signature *Please type your full name as proof of signature.Date of birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 SubmitSave & Continue LaterPlease do not fill in this field. 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