Energy Clearing Questionnaire 1Personal details2Home details3Overall Assessment4Consent Thank you for expressing interest in Momentum Feng Shui's Energy Clearing Service. Please complete as much of this initial 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 youName Date of birth MM slash DD slash YYYY Address City Postal code PhoneEmail Occupation Questions about spouseName Date of birth MM slash DD slash YYYY Occupation Do you live with other people (not including you or spouse)? Yes No Please write their name, date of birth and gender (one per line). What year was your Home built? What is the approximate S.F. of your living space (excluding rented suites if applicable)? 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 years?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 an Energy Clearing Consultation?Please share anything that you feel needs to be brought to my attention including a certain area of your Home: 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 to create the energy you want for your Home. 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 e-transfer to firstname.lastname@example.org. 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 and Energy Clearing. 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.Energy Clearing Service starts at $488 + GST, TOTAL $512.40 50% Deposit $256.20 Please make payment via e-transfer to: email@example.com Have you paid the required 50% deposit? Yes No Please provide reason Signature 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 enure 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 understand 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.