• Client Questionnaire Form

  • 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 & Back 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 at (661) 348-6237. I look forward to welcoming you to Willow Roots & Mane | The Bakersfield Head Spa.

  • Format: (000) 000-0000.

  • For the best experience, I use only the finest luxury professional-grade products in all services, carefully selected for their purity, performance, and scalp and skin benefits. My treatments feature premium clean beauty lines 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.

  • HEAD SPA COLLECTION

  • BACK SPA COLLECTION

  • ADD-ONS

  • Scalp Health & Service Safety

    This information helps us determine whether your Head Spa service can be safely performed or if modifications or rescheduling may be recommended.
  • Please check any that currently apply to you.

  • Current Scalp Health & Concerns

    Please select all that apply.
  • What is the current condition of your hair/scalp?
  • Where does your problem exist?

  • Natural Hair Texture & Curl Pattern

  • What is your natural curl pattern/texture pattern? select the option that best describes your natural hair, select all that may apply.

  • ✨ A little scheduling tip for the best results! ✨
    We recommend booking your hair color services either 1 week before your head spa appointment or 48 hours 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 1 week before your head spa can help prevent your toner from fading.

    Your hair and scalp will thank you! 💆‍♀️🌿

  • Back Spa & Mini Facial Questionnaire

    Please complete this questionnaire if you are booking a Back Spa or Mini Facial service, IF NOT PLEASE SCROLL DOWN TO THE BOTTOM OF THIS PAGE AND SKIP TO NEXT PAGE. Your answers help us customize your treatment and determine which products, techniques and treatment options are appropriate for your skin. Please let your provider know of any changes in your skin, medications or health before each appointment.
  • How would you describe your skin on the area being treated? select all that may apply
  • What are your main concerns for the skin on the area being treated? select all that may apply
  • Do you currently have any active breakouts on the area being treated?
  • Does your skin frequently react to skincare products, heat, exfoliation or fragrances?
  • Have you ever been diagnosed with or do you currently experience, any skin conditions? select all that may apply
  • Do you currently have any of the following on the area being treated?
  • Are there any moles, growths, lesions, or other areas on the area being treated you would like your provider to avoid?
  • Do you have any known allergies or sensitivities to skincare, cosmetic or botanical ingredients?
  • Have you ever experienced a reaction to any of the following?
  • Are you currently using prescription or over-the- counter acne medications on the area being treated?
  • Are you currently using retinol, tretinoin, adapalene, retinoids, exfoliating acids or prescription skincare on the area being treated?
  • Have you used isotretinoin ( Accutane ) or another oral prescription acne medication?
  • Are you currently taking any medications or supplements that affect your skin, increase skin sensitivity, increase bruising/bleeding, or cause photosensitivity?
  • Within the treatment area, have you recently had any of the following?
  • Have you had prolonged sun exposure, used a tanning bed or experienced a sunburn recently?
  • Are you currently pregnant, breastfeeding, or trying to conceive?
  • Do you have any health conditions that may affect your skin, healing, circulation, or ability to safely receive a skin treatment or massage?
  • Do you have diabetes or another conditions that affects sensation or wound healing?
  • Do you bruise or bleed easily or are you currently taking blood-thinning medication?
  • Have you recently had surgery, an injury, or do you currently have back, neck or shoulder pain that may affect your comfort during your service?
  • Is there anything you DO NOT want performed during your treatment?
  • How did you hear about me?

  • Name of person who REFERRED you         

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: