Conscious Healthy Home Client Application Form

Conscious Healthy Home™ Client Application
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number (please use the number you would like me to reach you at for the consultation call)*
Time Zone (note Conscious Healthy Home is on Central Time)*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Project Scope
Learn more about Conscious Healthy Home's services here.
Healthy Home Strategy AssessmentHealthy Home Building & Buying GuidanceTargeted improvements in a specific areaOngoing Healthy Home Support
Budget
$10,000-$50,000$50,000-$100,000$100,000-$500,000$500,000-$1,500,000$1,500,000-$2,500,000$2,500,000+
Property Details (if building or renovating)
Property Address
Year Built
Approximate Square Footage
Type of Property (Single-family, Townhome, Apartment)
Current Concerns
Indoor Air QualityWater QualityMold or Moisture/HumidityEMFChemical SensitivitiesAllergensLighting and Circadian RhythmsOther
Are there any specific health conditions or sensitivities in your household that we should be aware of?
Have you been (or are you currently) involved in any litigation regarding this or any prior home purchase/design/build/renovation project(s)?
Project Goals
List your top three (3) goals for this project
When would you like to begin this project, and is there a specific completion date in mind?
Have you worked with healthy home consultants or similar professionals before? If yes, please briefly describe your experience.
Investment
Yes, I am fully committed to the success of my projectI am interested but have some time constraintsI do not have the time to invest. I would like someone to make the choices for me and keep me informedI am unsure about my interest and availability
Yes, I am fully committed to being empowered to confidently make these project decisions on my own behalfI am interested in services where the decisions are made independently, without much input from me
Yes, I am ready to goI have financial constraints
What else do you think we should know?
Is there anything else you'd like to share about your needs or expectations for this project?
How did you hear about Conscious Healthy Home? Did someone refer you?*
Next Steps
If qualified, you will receive an email with a booking link. Please select a date and time for the initial 30-minute inquiry call. Note that the fee is $97 and portion of your fee will be donated to a charity of your choice--either Malachi's Message Foundation or Change the Air Foundation.
Should be Empty:

Conscious Healthy Home™ Client Application

Project Scope

Budget

Property Details (if building or renovating)

Current Concerns

Project Goals

Investment

What else do you think we should know?

Next Steps