Today's Date:_____________

 

Your name:___________________________________ Age:_______ Do you give us permission to contact you?:  Yes  No

 

Do you own the location that you want investigated?:   Yes   No

 

Your phone number: (_____) ________-____________  Email address:_______________________________________

 

Physical address:_____________________________________ City_________________State________Zip__________

 

Brief description of the location, example (1 story house, with 3 bedrooms, etc): _________________________________

 

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Age of the building(s):_________

 

When did you move to the location?:__________

 

History of the location (if you know of any evens that are connected to the property):______________________________

 

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Have you recently done any remodling to the location?:  Yes    No      

 

If you answered YES when was the remodling done?:_________________

 

Number of people in the location:_________  Please list their ages:___________________________________________

 

Chief complaint with the location:______________________________________________________________________

 

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________________________________________________________________________________________________

 

________________________________________________________________________________________________

 

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Have you had any trouble with your electrical appliances, plumbing, etc?:  Yes    No

 

Is anyone at the location interested or dabbled in the occult?  Yes   No

 

Are you or anyone at the location been seeing a therapist or psychiatrist, etc?   Yes   No

 

 

Please list any questions that you would like to ask us:______________________________________________________

 

_________________________________________________________________________________________________

 

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Please mail this form to:

KMPS

P.O. Box 1

Vancleve, Ky. 41385