Green Home and Living Consultation
Initial Survey: Concerns, Priorities and Goals
Transitioning to a more environmentally friendly life can be an overwhelming task without the right
resources, information and advice. Your Green Home & Living Consultant wants you to succeed and
stick with it and is here to break the process down for you and make it so easy and fun, you'll want to turn
your whole world green! Think of this first step as "narrowing the field" and of your consultant as your
personal environmental coach. Think about all those magazine quizzes you once took (or still take), grab
a pen and let your Consultant get to know you!
Please complete the questionnaire below and return it to your Green Home & Living Consultant with the
consultation fee and signed agreement. Your consultant will send you a customized consultation package
based on your indicated concerns, priorities and goals. The results from your custom consultation will
allow your consultant to tailor recommendations for you.
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Client Name (Please print in large block)
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Client Email Address and Phone Number
Part 1: Concerns, priorities and goals. Please rank the following, "0" being of no concern/not a
priority and "10" being of great concern/a high priority.
I am concerned about my carbon footprint. I would like to know what it is and how to reduce it if necessary.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the safety and quality of the food I eat/my family eats. (Number of adults: ____; Number of
children and their ages: _______________________)
0
1
2
3
4
5
6
7
8
9
10
8
9
10
I am concerned about the environmental impact of my/my family's diet.
0
1
2
3
4
5
6
7
I am concerned about the safety of the cosmetics and toiletries that I use. My goal is to learn what's in my cosmetics
and toiletries and how safe they are and to transition to safer options where necessary.
0
1
2
3
4
5
6
7
8
9
10
I am especially concerned about the safety and quality of the food my children eat.
0
1
2
3
4
5
6
7
8
9
10
I am especially concerned about the safety and quality of the food my pet eats. (Type of pet, age, and current pet
food: _______________________________________________________)
0
1
2
3
4
5
6
7
8
9
10
I am especially concerned about the safety of the toiletries that my children use. My goal is to learn what's in my
kids' toiletries and how safe they are and to transition to safer options where necessary. (Number of children and
ages: ____________________)
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the amount of waste I create and consider waste reduction a priority.
0
1
2
(Continued on back)
3
4
5
6
7
8
9
10
I am concerned about the environmental impact of the waste I dispose of and would like to know how to properly
dispose of and recycle problematic items.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the health of my home and consider reduction of indoor pollution a priority.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the chemicals used in and around my home and consider it a priority to transition to less
volatile and environmentally and physically harmful options.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about my level of consumption and consider it a priority to reduce my buying and spending.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the environmental impact of my consumption and consider buying more environmentally
friendly items and purchasing them in a less environmentally harmful way a priority.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the amount of material items I have accumulated and consider it a priority to dispose of these
things without wastefully throwing them away.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about supporting the local economy and would like to buy the goods and services I need locally.
0
1
2
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5
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8
9
10
I am concerned about the amount of water my household uses and consider it a priority to reduce water usage and
use water more efficiently.
0
1
2
3
4
5
6
7
8
9
10
I am concerned about the amount of energy my household consumes and consider it a priority to reduce energy
usage and use energy more efficiently.
0
1
2
3
4
5
6
7
8
9
10
(Note: Home energy use is a very broad topic and creates significant environmental impact. If this is a high priority,
or one among few high-priority items, your Green Home and Living Consultant may recommend a more extensive
and specific home energy audit for an additional fee. If you would like to request this in-depth, in-home audit
regardless of whether or not it is recommended for you, please sign here: _________________________________)
Please use this space to note any additional concerns or priorities that may not have been addressed above or
to emphasize or provide more detail on any of the above answers.
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