Name

First Name

Last Name

Prefered Pronouns

Phone

Optional

Country

(###)

###

####

Prefered Contact Method

Call

Text

Company Name

How did you hear about Quietus Ltd

Family/Friend

Fellow realtor

Presentation/Mastermind Group

Internet Search

Other

In Your Own Words, Please Describe the Issue(s) You are Experienceing.

How long have these issues been going on?

Have you tried mundane solutions to resolve the issue(s)?

ex. An electrician has inspected the wiring in an attempt to resolve flickering lights The A/C unit and fans have been shut off to attempt to resolve cold breezes felt. Please explain.

Have You Retained the Services Other Energyworker Professionals to Resolve the Issue?

Yes

If Yes, Please Provide the Name(s) of Who Assisted You.

We may need to contact them for additional background information regarding your issue(s).

The Address of the Property in Question

1234 North Someplace Drive

Any known pertinent information regarding the property?

Births, Death, Fires, etc.

Desired Outcome for the Property

Acknowledgment

I understand that by making an appointment with a representative of Quietus Ltd, that I am paying for that individual's time. Consultations are process, not a quick fix and I understand that I have a responsibility to follow through with the tools and suggestions for personal protection as they are made available to me. Representatives of Quietus Ltd are Spiritual Consultants, and as such are sharing their truth and experience regarding spiritual matters. Though every effort will be made to facilitate attachment removal, energetic clearings/cleansings and discernments there is not guarantee to the accuracy rate of a consultation. Representatives of Quietus Ltd are not health care professionals, psychotherapists or grief counselors.

I have read, acknowledge and accept the above statement.

yes

Informed Consent

All modalities used are designed to integrate physical, mental, emotional and spiritual aspects of an individual, their home, office or property. They can be helpful in identifying and releasing geopathic and electromagnetic pollution in home, office or property. While we do our best to resolve issues, please note that locational, economic and environmental obsolescence can be factors in determining continued resolution in the future. All available tools will be utilized in your case, as we will support what ever is in the highest and best options for our clients. None of the modalities offered by Quietus Ltd are a replacement for standard medical treatment. If you are seeing a medical doctor or Phsycologist for any health problems, please continue to see that/professional(s). Our services should be considered spiritual in nature and members of Quietus Ltd are holistic health practitioners, not licensed physicians. Because modalities are unproved and experimental according to the Colorado Board of Examiners, the spiritual healing modalities offered have not demonstrated their effectiveness to the Colorado Board of Examiners or any other medical examiner. I have read and understand this explanation and have had my questions answered to my satisfaction. I understand that any home or office clearing facilitated by Quietus Ltd and its representatives may not be covered by insurance. In accordance with the above understanding, I hereby agree on behalf of myself, my heirs, executors, administrators, personal or legal representatives or any other person on my behalf to release Quietus Ltd and its agents and representatives harmless from any and all claims or demands resulting from bodily injury, accident, emotional trauma, death, loss or damage to personal effects. My signature certifies that I have carefully read and fully understand the agreement herein, and I understand that this is legally binding and enforceable between Quietus Ltd (its agents and representatives) and myself. If I choose to hire Quietus Ltd, I acknowledge that I am hiring a company to help with my spiritual needs. I have signed this document of my own free will. I am over 18 years old

Electronic Signature

By checking this box, I verify the above will serve as my signature for all matters.

I accept this as my Electronic Signature

Thank you for reaching out to Quietus Ltd. Due to the volume of requests, please allow 24-48 hours for us to contact you.

Clearing Questionnaire

This Service is offered to Real Estate Professionals and Property Managers Only.

Quietus Ltd