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The Triads First Headspa

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Client Intake Form

Client Intake Form

First Name*

Last Name*

Phone*

Email

Birthday*

Month

Day

Year

Emergency Contact - Name

Emergency Contact - Phone

Health & Wellness

Check all that apply*

Pregnancy

High blood pressure

Heart conditions

Migraines or frequent headaches

Neck, shoulder, or back pain

Recent surgery or injury

Sensitivity to pressure or touch

Anxiety or sensory sensitivity

None of the above

Hair & Scalp History

How would you describe your scalp?

Check all that apply*

Dry

Oily

Flaky

Sensitive

Itchy

Balanced

Do you experience hair thinning or hair loss?*

Yes

No

Do you have dandruff or buildup?*

Yes

No

Do you use heat styling tools regularly?

Yes

No

How often do you wash your hair?*

Skin & Sensitivities

Do you have sensitive skin?*

Yes

No

Do you prefer light, medium, or firm pressure?*

Light

Medium

Firm

Do you prefer quiet relaxation or light conversation?*

Quiet Relaxation

Light Conversation

Are there any scents you dislike or wish to avoid?

Goals for Your Experience

What would you like to focus on today? (check all that apply)

Check all that apply*

Deep relaxation

Stress relief

Scalp health

Hair hydration or repair

Tension relief (neck/shoulders/head)

Overall wellness and balance

Anything else you’d like me to know to enhance your experience?

Consent & Acknowledgment

I understand that head spa services are for relaxation and wellness purposes only and are not a substitute for medical treatment. I have disclosed all relevant health information to the best of my knowledge.

Full Name *

Date*

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