Scalp client questionnaire

Client Questionnaire Form

What’s your hair/scalp history?
Welcome to Willow Roots & Mane, where every experience is thoughtfully curated to promote scalp health, healthy hair, and deep relaxation. Below you'll find my signature collection of luxury head spa services, complete with detailed descriptions and pricing to help you select the experience that best aligns with your individual needs.Once you've reviewed the services, please complete and submit your Client Questionnaire. I will personally follow up with you via text to welcome you and provide my current appointment availability. If you have any questions before booking, please don't hesitate to reach out by text or call at (661) 348-6237. I look forward to welcoming you to Willow Roots & Mane | The Bakersfield Head Spa.
Client’s Name

First NameLast Name
Client's Phone Number
Format: (000) 000-0000.
Email
example@example.com
Birth Date ( if under 18 )

MonthDayYear
Guardian Name

First NameLast Name
New or Returning client
Are you redeeming a gift card? If so, please type in the gift card number.
Do you have any skin/topical allergies to products?
ALLERGY WARNING: Organic products are used in the head spa services. Please be advised that the organic products may contain coconut and nut oils, essential oils fragrances, herbal botanicals, seed oils, sugars, clays, vegetable oils and other ingredients.
Are you pregnant?
If you are pregnant, it is advised you contact your medical provider for any concerns about the head spa service. I am not a medical doctor and cannot medically advise you in regards to your safety during a head spa service. It is advised you get clearance from your medical provider before booking your appointment. During the service you will be laying on your back up to 45-60 minutes with legs elevated on a leg elevation pillow. Heat will only be applied to your head with a micro mist cap, up to 10 minutes, twice during the service. You can request to have the heated micro mist cap excluded from your service. Yours and your baby’s safety come first. I can accommodate pregnant clients during their 1st and 2nd trimesters, provided they can comfortably lay flat on their back for at least one hour. I do not recommend services during the 3rd trimester due to comfort and safety reasons. Thank you for understanding.
For the best experience, I use only the finest luxury non-toxic professional-grade products in all services, carefully selected for their purity, performance, and scalp and skin benefits. My treatments feature premium clean beauty lines including Oway Organics, Areté, Curlstate, Intelligent Nutrients, and FarmHouse Fresh, ensuring a high-performance experience that supports true scalp wellness, hair health, and skin vitality without compromising on luxury or safety. All Head Spa packages conclude with Nourishing scalp serum • Leave-In Smoothing or Curl hair cream with Heat protector • light blow dry • Please check your services below.

SIGNATURE HEAD SPA $180 ( 1 hour 30 minutes) Indulge in the ultimate luxury scalp wellness experience, thoughtfully designed for healthy scalps with little to no buildup. The Signature Head Spa is a restorative treatment that blends advanced scalp care with deep relaxation to nourish the scalp, revitalize the hair, and calm the mind.Your experience begins with a personalized consultation and in-depth scalp analysis, where we'll discuss your scalp health, hair concerns, and any signs of hair thinning or hair loss while reviewing before-and-after scalp images. Every treatment is then customized to meet your unique scalp and hair needs.Unwind with a luxurious pressure-point scalp massage using a nourishing botanical oil to help melt away tension, improve circulation, and encourage an optimal environment for healthy hair growth. A gentle head steam enhances the absorption of treatments while promoting complete relaxation.Your journey continues with a soothing décolleté, shoulder, and upper arm massage before a second customized scalp massage using a pre-cleanser selected specifically for your hair and scalp type. A personalized scalp treatment is followed by a detoxifying deep-cleansing shampoo to refresh the scalp and remove impurities, then a rebuilding hair mask to restore softness, strength, and shine.The experience concludes with our signature purifying waterfall rinse, leaving you feeling deeply relaxed, refreshed, and renewed from scalp to soul. •Ideal for: Healthy scalps with little to no buildup, those seeking preventative scalp care, stress relief, and a luxurious self-care experience while promoting optimal scalp health and beautiful, healthy hair. Men, women, children ( 8 years old & up ).DETOXIFYING HEAD SPA $215 ( 1 hour 45 minutes) Refresh and rebalance your scalp with our Detoxifying Head Spa, an intensive cleansing treatment designed to remove stubborn buildup, restore scalp balance, and create the ideal foundation for healthier hair growth. This luxurious experience is perfect for those struggling with dandruff, excessive product buildup, oily scalps, or congested follicles that leave the scalp feeling heavy and unhealthy.Your experience includes everything featured in our Signature Head Spa, beginning with a personalized consultation and advanced scalp analysis to evaluate your scalp's condition, identify areas of concern, and discuss any scalp or hair issues, including dandruff, buildup, or hair thinning. Before-and-after scalp images allow you to see your scalp's transformation while ensuring every treatment is customized to your individual needs.Unwind with an extended pressure-point scalp massage using a nourishing botanical oil to relieve tension, increase blood circulation, and support a healthy environment for hair growth. A gentle head steam enhances the penetration of treatments while promoting deep relaxation, followed by a soothing décolleté, shoulder, and upper arm massage.This treatment is elevated with an extended scalp exfoliation to gently lift away excess oil, dead skin cells, product residue, and stubborn dandruff buildup, leaving the scalp feeling exceptionally clean and refreshed. A premium scalp treatment infused with chamomile and rosemary helps calm irritation, reduce inflammation, support a healthy scalp microbiome, stimulate circulation, and nourish the scalp for optimal scalp health.Your experience continues with a customized pre-cleanser scalp massage, detoxifying deep-cleansing shampoo, rebuilding hair mask, and concludes with our signature purifying waterfall rinse, leaving your scalp deeply purified, balanced, and revitalized while your hair feels refreshed, soft, and full of life. •Ideal for: Clients experiencing dandruff, excessive product buildup, oily or congested scalps, or anyone seeking a deep scalp detox to exfoliate, rebalance, and restore a healthier scalp environment.Men, women, children ( 8 years old & up ).HEALING HEAD SPA $215 (1 hour 45 minutes) Restore balance to an irritated scalp with our Healing Head Spa, a therapeutic luxury treatment thoughtfully designed to calm inflammation, relieve discomfort, and support long-term scalp health. This restorative experience combines advanced scalp care with deep relaxation, making it ideal for those experiencing psoriasis, eczema, scalp sensitivity, or chronic irritation.Your experience includes everything featured in our Signature Head Spa, beginning with a personalized consultation and advanced scalp analysis to evaluate your scalp's condition and discuss any concerns, including inflammation, dryness, buildup, or hair thinning. Before-and-after scalp images allow you to see your scalp's progress while ensuring each treatment is fully customized to your needs.Relax with an extended pressure-point scalp massage using a nourishing botanical oil to help reduce tension, increase circulation, and encourage a healthy environment for hair growth. A gentle head steam enhances the penetration of treatments while promoting complete relaxation, followed by a soothing décolleté, shoulder, and upper arm massage.This healing ritual is elevated with a premium chamomile-infused scalp treatment, selected for its naturally calming and anti-inflammatory properties. Chamomile helps soothe irritation, reduce redness, and comfort sensitive, reactive scalps while supporting the skin's natural healing process.For guests experiencing psoriasis buildup, a gentle scalp exfoliation is incorporated to help lift and loosen surface flakes, allowing nourishing treatments to better penetrate the scalp without causing unnecessary irritation.The experience continues with a customized pre-cleanser scalp massage, detoxifying deep-cleansing shampoo, rebuilding hair mask, and concludes with our signature purifying waterfall rinse, leaving your scalp feeling comforted, refreshed, and deeply nourished. •Ideal for: Clients experiencing psoriasis, eczema, scalp sensitivity, inflammation, or irritation who are seeking a gentle, restorative treatment that promotes comfort, balance, and a healthier scalp environment. Men, women, children ( 8 years old & up ).REVITALIZING HEAD SPA $215 ( 1 hour 45 minutes) Elevate your scalp wellness journey with our Revitalizing Head Spa, an enhanced version of our Signature Head Spa designed to deeply nourish, soothe, and restore the scalp while creating the ideal foundation for healthier, fuller-looking hair. This luxurious experience includes everything featured in our Signature Head Spa, beginning with a personalized consultation and advanced scalp analysis to assess your scalp health and address any concerns, including hair thinning or hair loss. Before-and-after scalp images allow you to see your scalp's transformation while ensuring every treatment is tailored specifically to your needs. Relax into an extended pressure-point scalp massage using a nourishing botanical oil to ease tension, improve circulation, and encourage a healthy environment for hair growth. A calming head steam enhances the absorption of treatments while promoting complete relaxation, followed by a soothing décolleté, shoulder, and upper arm massage. Your experience is elevated with a premium rosemary-infused scalp treatment, customized for normal to dry scalps. Rich in anti-inflammatory and antioxidant properties, rosemary helps calm scalp irritation, support a balanced scalp microbiome, increase blood circulation, and stimulate hair follicles to encourage healthy hair growth. This deeply nourishing treatment helps restore hydration while promoting long-term scalp health. The treatment continues with a customized pre-cleanser scalp massage, detoxifying deep-cleansing shampoo, rebuilding hair mask, and concludes with our signature purifying waterfall rinse, leaving your scalp refreshed, your hair beautifully revitalized, and your body completely relaxed. •Ideal for: Normal to dry scalps, those experiencing dryness or mild irritation, and anyone seeking enhanced nourishment, improved scalp circulation, and a luxurious treatment that supports healthy hair growth and overall scalp wellness. Men & women.GENTLEMEN’S RETREAT HEAD SPA $230 ( 1 hour 45 minutes) Designed specifically for the modern man, the Gentlemen’s Retreat Head Spa is a luxury grooming and wellness experience that blends advanced scalp care with a revitalizing mini facial. This treatment is ideal for those seeking deep relaxation, scalp health maintenance, and a refreshed, polished appearance from head to skin. Your experience includes everything featured in our Signature Head Spa, beginning with a personalized consultation and advanced scalp analysis to assess scalp health, address concerns such as dryness, oiliness, buildup, or hair thinning, and ensure every step is fully customized to your needs. Before-and-after scalp images are taken to track your scalp’s transformation and overall improvement. Unwind with a nourishing pressure-point scalp massage using botanical oil designed to relieve tension, increase circulation, and support healthy hair growth. A calming head steam enhances treatment absorption while promoting deep relaxation, followed by a soothing massage of the shoulder and upper arms to release built-up stress and tension.The experience continues with a second customized scalp massage using a pre-cleanser tailored to your hair and scalp type, followed by a detoxifying deep-cleansing shampoo, a rebuilding hair mask, and our signature purifying waterfall rinse to leave the scalp feeling clean, balanced, and renewed.To complete the experience, enjoy a revitalizing mini refresh facial customized to your skin type. This includes a gentle face steam to open pores, a soft cleansing treatment to remove impurities, a warm towel compression, a customized facial mask, and a hydrating moisturizer to restore balance and glow. For clients with facial hair, a nourishing beard balm is applied to soften, condition, and refine the beard. •Ideal for: Men seeking a full head-to-skin reset, stress relief, scalp maintenance, and a refined grooming experience that promotes relaxation, healthy hair growth, and refreshed, balanced skin.ADD-ON Skin Refresh Mini Facial: 35 MINUTES $75- The perfect pick-me-up for your skin. Our Skin Refresh Mini Facial is a results-driven yet relaxing treatment designed to cleanse, nourish, and revive your complexion in under forty minutes. Using clean, farm-fresh skincare from FarmHouse Fresh, this facial is customized for all skin types—oily, dry, acne-prone, combination, and aging skin.Your service begins with soothing facial steam and a gentle cleanse, followed by light exfoliation to smooth and refresh the skin. A warm hot towel prepares your complexion for a customized facial mask, while a relaxing facial massage with nourishing oilpromotes circulation and glow. The treatment is finished with toner, moisturizer, and a hydrating lip mask for a soft, balanced, and refreshed finish.Perfect for anyone needing a quick skin reset.✨ Includes:• Facial steam• Cleanse• Gentle exfoliation• Hot towel• Customized facial mask• Facial massage with nourishing oil• Toner & moisturizer• Lip maskADD-ON BLOW DRY $35 &up. Price varies on hair texture, thickness and length. A simple finishing service designed to safely and gently dry the hair after your treatment. Your hair is prepped with organic, non-toxic products customized to your hair type to support moisture, shine, and overall hair health. A professional heat protectant is applied to help shield the hair from heat while maintaining its integrity. This service focuses on efficiently drying the hair while leaving it clean, refreshed, and naturally finished without styling or smoothing.( This is not a blow out. Blow drying is meant to dry and reduce frizz , a blow out adds volume and style to hair using a round brush. )
Head spa treatments cannot be performed on clients who have the following.. please check if any apply.
What is the current condition of your hair/scalp?

Other
Where does your problem exist?

Other
When did you first notice scalp problem?
Has a dermatologist and or doctor ever diagnosed you with a scalp disorder or disease?
If yes, what and when was the diagnosis?
How long is your hair?
Medium is on or around your shoulders
✨ A little scheduling tip for the best results! ✨
We recommend booking your hair color services either 2 weeks before your head spa appointment or 1 week after. This helps us get the most accurate scalp analysis since fresh color can sometimes leave temporary stains.

If you’ve had a head spa, giving your scalp a week of rest before coloring helps avoid irritation—your pores are opened during the treatment and need time to soak up all the benefits.

And if you’ve recently had highlights, waiting about 2 weeks before your head spa can help prevent your toner from fading.

Your hair and scalp will thank you! 💆‍♀️🌿
Any special instructions, comments, or suggestions?
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Client Questionnaire Form