Dowsing Client Intake Form Please fill out the form below and submit to me prior to your Dowsing appointment. Thank you. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Email * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Phone * Did someone refer you? If so, who? (I would like to thank them!) What year was your home built? How long have you lived in your home? * How many people are living in your home? * List their names and ages below. Any pets? (Please list names and type - cat, dog, bird) Why are you interested in Dowsing your home? * Is anyone having health problems or concerns? Is anyone having problems sleeping? (who?) Does anyone have problems with lack of focus, headaches or memory issues? (who?) Does anyone in your family feel tired and fatigued while being in your home? (who?) Are there rooms/areas that are constanly cluttered? (Please list) Are there rooms/areas that people avoid or don't like spending time in? (Please list) Are there rooms you enjoy being in? (Please list) Does anyone see, feel or sense spirits in your home? (who?) Is there anything else you want to share about your home?