Scalp client questionnaire

Client Questionnaire Form

What’s your hair/scalp history?
Thank you for your interest in booking a head spa! Please fill out and submit your client questionnaire and I will follow up with you via text, within 24hrs, with my current availability.

Feel free to text me with any questions 661-348-6237
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.
All Head Spa packages ( EXCLUDING The Gentlemen’s Retreat ) include: •15 minute client consultation. (Scalp Analysis, educate, recommendations)•Scalp massage with organic soothing oil• Micro- mist head steamer• Light massage. Décolletage, shoulders, upper arms. (age 18+ women only)•Second scalp massage with pre-cleanser• Gentle scalp brushing, buildup removal•Customized Scalp Treatment•Detox Shampoo• Rebuilding Hair Mask• Guasha comb• Waterfall rinse• Review Before & After Photos •Thermal protection spray• Conclude with light blow dry -What type of service are you interested in?*

SIGNATURE HEAD SPA ( 90 minutes ) -$195 [ Any 90 minute gift cards purchased prior to May 17th will retain its original purchase price of $175. You will not be required to pay the difference. ] CLARIFYING AND NOURISHING SCALP TREATMENT. IDEAL FOR NORMAL/DRY/OILY SCALPS WITH MINIMAL TO NO ACCUMULATION OF BUILDUP. Experience the ultimate in scalp health with our holistic scalp treatment service. This unique service is designed to purify, nourish, and rejuvenate your scalp, creating the perfect foundation for healthy hair growth. We use a blend of natural ingredients, rich in essential nutrients, to gently cleanse and detoxify your scalp. This process helps to remove product buildup and excess oil, allowing your scalp to breathe.Next, we nourish your scalp with a specially formulated treatment, packed with vitamins and antioxidants. This step helps to restore balance, promoting a healthier scalp environment. Finally, a soothing scalp massage stimulates blood circulation, encouraging healthier hair growth.Our holistic scalp treatment service is more than just a treatment; it's a journey to healthier, happier hair. It's about understanding the importance of scalp health and how it impacts your overall hair health. Inspired by the serenity and depth of the forest edge, our Micro-Exfoliating Scalp Treatment harnesses the power and strength of various trees, stones and mycelium to reveal a healthy, balanced scalp biome at the root. Upcycled Bamboo gently decongests the follicle, promoting healthy hair growth and nutrient uptake and White Willow Bark helps dissolve and remove scalp buildup.♥ Helps to balance the scalp biome♥ Increases moisture retention to relieve dryness and irritation♥ Gently decongests follicles, promoting healthy hair growth and nutrient uptake♥ Helps dissolve buildup, impurities and regulates oil production. DHT INHIBITING SERUM- Thicker, fuller hair starts at the scalp, and this Pure Plenty Nourishing Scalp Serum works at the source to support hair follicle health while inhibiting the hair-thinning hormone DHT. Our advanced Intelli-Cell™ plant stem cell science promotes your healthiest hair cycle and helps protect the length you’ve got.DETOXIFYING HEAD SPA ( 105 Minutes ) $240 DEEP DETOXIFYING + REJUVENATING SCALP TREATMENT. IDEAL FOR SCALPS WITH DANDRUFF ( dry/oily), PRODUCT BUILDUP AND ITCHY SCALP. Say goodbye to itchy, flaky scalps with our specialized spa service! Our expert therapist uses a blend of natural ingredients and advanced techniques to gently cleanse your scalp, removing buildup and dandruff. This treatment not only leaves your scalp feeling fresh and clean, but also promotes healthier hair growth. It's the perfect way to relax, unwind, and give your scalp the care it deserves. Treat yourself to a rejuvenating scalp therapy session and let your hair shine with health and vitality!Oway Pure Biodynamic Thyme is a 100% pure and effective herbal remedy for relieving itching and burning associated with dandruff. It's all natural antimicrobial action reduces malassezia - the fungus responsible for causing dandruff.Pure Biodynamic Thyme is hand picked and harvested with zero chemicals on OrtOfficina - Oway's 50,000 sqm of biodynamic family farmland in Bologna, Italy. It's micronized plant form is ideal for optimal skin and scalp absorption.♥ Relieves itching and burning associated with dandruff♥ Combats the dandruff-causing fungus malassezia♥ Refreshes and purifies the scalp by regulating sebum productionOway Purifying Rice Wax deeply exfoliates and eliminates oily or dry dandruff buildup with micro rice granules. Its effective blend of Biodynamic Rosemary Essential Oil and Thyme works to refresh and regulate the scalp.♥ Gently removes dandruff and flaking♥ Promotes microcirculation of the scalp♥ Purifies and the scalp and regenerates the scaling skin. DHT INHIBITING SERUM-Thicker, fuller hair starts at the scalp, and this Pure Plenty Nourishing Scalp Serum works at the source to support hair follicle health while inhibiting the hair-thinning hormone DHT. Our advanced Intelli-Cell™ plant stem cell science promotes your healthiest hair cycle and helps protect the length you’ve got.HEALING HEAD SPA ( 105 Minutes ) $240 DETOX + SOOTHING TREATMENT. IDEAL FOR ECZEMA, PSORIASIS AND OTHER IRRITATED OR SENSITIVE SCALP TYPES. Experience the ultimate relief with our specialized scalp service, designed specifically for those dealing with psoriasis. Our treatment not only soothes your scalp, but also effectively removes any buildup, leaving you with a refreshed and healthier scalp. We use gentle, yet powerful, techniques to alleviate discomfort and reduce the appearance of flakes. Our goal is to provide you with a comfortable and relaxing experience while we work on improving your scalp health. Say goodbye to irritation and hello to a soothed, clean scalp. Oway Pure Biodynamic Helichrysum is a 100% pure and effective herb for soothing and repairing red, irritated scalps and skin. Known as the Immortal Flower, it delivers anti-aging benefits by protecting the skin from oxidation.Pure Biodynamic Helichrysum is hand picked and harvested with zero chemicals on OrtOfficina - Oway's 50,000 sqm of biodynamic family farmland in Bologna, Italy. It's micronized plant form is ideal for optimal skin and scalp absorption.♥ Soothes and calms red, irritated scalps and skin♥ Protects the skin and scalp from aging and oxidationOway Zanthoxylum Soothing Gel harnesses the power of the Ancient Chinese herb, Zanthoxylum, which offers the skin and scalp immediate relief from redness and irritation. Botanical-based Allontoin reduces healing times from inflammation, wounds and sunburn.Oway Soothing Remedy relieves red, irritated skin and scalps with a healing blend of Biodynamic Chamomile, Zanthoxylum Flower and Organic Aloe Vera. Skin is instantly soothed and moisturized. Great for alleviating sensitive skin.♥ Calms redness and irritation♥ Alleviates any itching or discomfort♥ Heals and moisturizes a sensitive skinREVITALIZING HEAD SPA ( 105 MINUTES ) $235 BOTANICAL DETOX + STRENGTHENING SCALP TREATMENT. IDEAL FOR NON-PROBLEMATIC SCALPS WITH MINIMAL TO NO ACCUMULATION OF DANDRUFF OR PRODUCT BUILDUP. NO SENSITIVITIES. Our scalp treatment service is like a spa day for your hair. It's designed to detoxify and strengthen both your scalp and hair, giving them the care they truly deserve. We start by gently cleansing your scalp, removing any build-up of product or natural oils that can clog your hair follicles. This detoxifying process helps to rejuvenate your scalp, promoting healthier hair growth. Next, we nourish your scalp with a blend of anti-aging essential nutrients. This step is all about strengthening your hair from the roots, making it more resilient to damage and breakage. But our service doesn't stop at just detoxing and strengthening. We also focus on maintaining the overall health of your scalp and hair. Our expert will provide you with personalized advice on how to keep your scalp and hair in top condition. In essence, our scalp treatment service is more than just a treatment; it's a commitment to healthier, stronger hair. Give your hair the love it deserves today.Its 100% natural ingredients have a gentle peeling effect to deeply cleanse and purify the scalp, promoting healthy hair growth and scalp function.The medicinal properties of Biodynamic Savory Leaves, Organic Horsetail and Fair Trade Amazonian Pink Clay eliminate built up toxins and impurities, while strengthening and regenerating the hair and scalp.♥ Reveals softer, more supple skin and hair♥ Gently cleanses the skin and scalp with a slight peeling action♥ Eliminates stress-inducing toxins from the skin and scalpOway Strengthening Essential Oil Blend is made with 100% pure steam-distilled essential oils of Biodynamic Mint, Rosemary, Thyme and Lemon. Together, these medicinal botanicals create a healthy scalp eco-system that promotes hair growth and strength.♥ Stimulates microcirculation of the scalp, promoting healthy hair growth and strength.Oway Densifying Remedy - a highly concentrated organic scalp treatment intended to strengthen the hair bulb and stimulate dermal papillae to help promote healthy hair growth. This innovative formula of Buddleja Davidii Plant Stem Cells, Dynagen and Denisplant densify hair follicles and prolong the hair's anagen (growth) phase.THE GENTLEMEN’S RETREAT (90 MINUTES ) $240 CLARIFYING AND NOURISHING SCALP TREATMENT. IDEAL FOR NORMAL/DRY/OILY SCALPS WITH MINIMAL TO NO ACCUMULATION OF BUILDUP. This head spa package includes: 15 minute client consultation. (Scalp Analysis, educate, recommendations)•Scalp massage with organic soothing oil• Micro- mist head steamer• Gentle facial cleanser • Facial clay mask • Facial moisturizer • Beard Balm •Customized Scalp Treatment•Detox Shampoo & second scalp massage •Gentle scalp brushing, buildup removal• Guasha comb• Waterfall rinse• Review Before & After Photos •Scalp Serum• Step into a world of pure relaxation with our Gentlemen’s Retreat Head Spa Treatment. This isn't just a spa treatment, it's a journey designed specifically for men, focusing on the head and face to deliver a truly invigorating experience.Your journey begins with a detailed scalp analysis. Our expert will examine your scalp to understand its unique needs and tailor the treatment accordingly. This is followed by a relaxing scalp massage using soothing organic oil that will melt away any stress and tension, setting the tone for the rest of your experience.Next, we gently cleanse your face with our organic face cleanser, designed to remove impurities without stripping your skin of its natural oils. This is followed by a facial clay mask, tailored specifically for your skin type. Whether you have oily, dry, or combination skin, we've got you covered.Once the mask has worked its magic, we apply a face moisturizer that's gentle enough for all skin types and non-comedogenic, ensuring your pores remain clear and your skin feels soft and supple.For those sporting a beard, we have a special treat in store. Our organic beard balm will condition your beard, leaving it soft, manageable, and smelling great.But we're not done yet. We then move on to a scalp treatment designed to nourish and rejuvenate your scalp, followed by a scalp exfoliation using a gentle scalp brush. Inspired by the serenity and depth of the forest edge, our Micro-Exfoliating Scalp Treatment harnesses the power and strength of various trees, stones and mycelium to reveal a healthy, balanced scalp biome at the root. Upcycled Bamboo gently decongests the follicle, promoting healthy hair growth and nutrient uptake and White Willow Bark helps dissolve and remove scalp buildup.♥ Helps to balance the scalp biome♥ Increases moisture retention to relieve dryness and irritation♥ Gently decongests follicles, promoting healthy hair growth and nutrient uptake♥ Helps dissolve buildup, impurities and regulates oil production. Next, a scalp detox shampoo along with a relaxing scalp massage to remove any build-up and leave your scalp feeling fresh and clean.The grand finale is a relaxing waterfall head rinse. Imagine the sensation of a gentle waterfall cascading over your head, washing away the stresses of the day. It's the perfect end to a perfect treatment. DHT INHIBITING SERUM- Thicker, fuller hair starts at the scalp, and this Pure Plenty Nourishing Scalp Serum works at the source to support hair follicle health while inhibiting the hair-thinning hormone DHT.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. ( 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. ) [ Any blow dry add-ons purchased prior to May 17th will retain its original purchase price of $25. You will not be required to pay the difference. ]
Head spa treatments cannot be performed on clients who have the following.. please check if any apply.

Severe scalp irritation with open soresHair Extensions ( all types ). Scalp treatments are suggested in between hair extensions applications. Massage friction can cause damage to the hair.Braids or twists. Scalp treatments are suggested during in between braids or twists applications.Scalp irritation that may be infectiousHave had a recent hair-color service. It's suggested to wait 1 week before or after color service to avoid scalp irritation.Oozing sores on scalpScalp abrasionsRingwormLiceOther infectious scalp disorderHigh blood pressure that is not under control. The increased blood flow that is a result of massage therapy may cause problems.Scalp burnsScalp irritation with bleedingFashion/Vivid Colors. Fashion/Vivid colors are prone to fading due to the use of lukewarm water, deep cleansing of the scalp and use of deep cleansing products.Brazilian Keratin Treatment. It’s suggested to wait 6 months or longer after having a keratin treatment done . Head spa treatment can possibly strip any keratin from hair which will affect the Keratin Treatment longevity.Heavy scalp plaque buildup due to psoriasis or seborrheic dermatitis.Severe Scalp irritation with pain, discomfort or inflammation due to psoriasis or seborrheic dermatitis.None of the above
What is the current condition of your hair/scalp?

Hair lossHair damage due to heatSplit endsHair breakageItchy scalpHair drynessDandruffHair damage due to color servicesScalp drynessOily scalpScalp rednessSeborrheic dermatitisScalp disordersScalp tendernessScalp sensitivity to touchBumpy scalpRaised scalp areasScalp burningScalp tightnessScalp lesionsPsoriasisOther
Where does your problem exist?

Frontal AreaTop of headPatchyAll overOther
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?
How did you hear about me?

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Client Questionnaire Form

Thank you for your interest in booking a head spa! Please fill out and submit your client questionnaire and I will follow up with you via text, within 24hrs, with my current availability.