Conscious Healthy Home Client Application Form

Conscious Healthy Home™ Client Application
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number
Time Zone (note Conscious Healthy Home is on Central Time)*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Project Scope
What services are you interested in exploring?

Healthy Home Strategy AssessmentHealthy Home Building & Buying GuidanceTargeted improvements in a specific areaOngoing Healthy Home Support
Budget
Outside of consulting costs, what is your estimated project 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
What are your primary concerns regarding the health of your living environment? (Check all that apply)

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.
Availability
We typically begin with a detailed initial consultation. Please indicate your preferred timeframe for your kickoff call:

Within the next weekWithin the next monthWithin the next three (3) monthsFlexible / No specific timeframe
Please provide at least 3 dates and times of specific availability for the initial consultation. Initial consult calls are 30 minutes ($97 investment).
Investment
Our services often require a significant time commitment from clients to achieve success. Are you prepared to invest the necessary time in this process, which may include multiple meetings and ongoing communication?

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
Our services are best suited for individuals committed to making informed, empowered decisions about their project. Does this describe you?

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
If we determine your goals and our services are a good fit, are you prepared to move forward with the financial investment in our services.

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?*
Should be Empty:

Conscious Healthy Home™ Client Application

Project Scope

Budget

Property Details (if building or renovating)

Current Concerns

Project Goals

Availability

Investment

What else do you think we should know?