Scalp & Hair Consultation

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Holistic Hair Wellness 24706 75th Street Paddock Lake, Wi 262-558-8090
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First Name* This field is required.
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Last Name* This field is required.
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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What has attracted you to Holistic Hair Wellness?* This field is required.
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What do you love about your hair?* This field is required.
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What do you like about your hair?
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What do you dislike about your hair?* This field is required.
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How much time would you like to spend on your hair?
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How often do you wash your hair?* This field is required.
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What do you use to wash and condition?* This field is required.
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What is your styling routine and what do you use?* This field is required.
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Please upload 2-3 photos of your hair as it looks today. We would like to see it from the back and the front, unfiltered. In natural sunlight is best
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Are you experiencing hair loss?* This field is required.
YESNO
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If yes how concerned are you?
A little concerned
I've noticed more than usual hair loss I'm concerned
I've noticed a lot of hair loss I am very concerned
I am very scared I'm losing so much hair
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Do you have scalp concerns* This field is required.
YESNO
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If yes what are your concerns?Check all that apply
Build up
Very Oily
Dandruff
Dry
Sensitive
Itchy
Other please explain
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Stress?Check all that apply
Yes
No
Other
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How do you meditate/ or take time for yourself to relax?
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How much water do you drink in a day?
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What medications do you take and what are they for?What we put into our bodies comes out our skin and on our hair.
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What do you do for a Career or Work?What is your day to day environment?
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What ways do you workout?
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I eat Check all that apply
Fast Food
Processed Food
Veggies
Fruit
Dairy
Red Meat
Poultry
Sea Food
Nuts
Breads
Whole Grains
Food Alternatives
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Check off all of the experiences you are interested in.
Revitalized Scalp
Soothed Scalp
Fresh Scalp
Soft Hair
Strong Hair
Silky Hair
Smooth Hair
Help Me Relax and Be In The Moment
I Want To Be Pampered
I Need To Relax
Scalp Massage
Neck Shoulder Arm Massage
Shoulder Arm & Upper Back Massage
Grey Completely Gone
Grey Blended Away
Seeing Highlights only in front
Seeing Highlights on top and in front
Seeing Highlights on top, in front and in back
Seeing Highlights just at the bottom of your hair not on top
Want to keep as much hair length as possible. Just want the very tips of your hair trimmed
Trim off about 1/2 - 1 an inch
Cut off whatever needs it
Want a new style haircut
Blow dry Style
Quick Don't Get Sick dry roots
Want Lots of Volume Blow dry Style
Want To See All My Curls
Want My Hair As Straight As Possible
Please Add Some Curls
Other
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Color Inspiration PhotosPlease upload 1-2 photos of your hair Color goals. You can find inspiration photos through google image search, Instagram, Pinterest or anywhere else you've seen hair you admire.
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Haircut & Style Inspiration PhotosPlease upload 1-2 photos of your HAIRCUT & STYLE goals. You can find inspiration photos through google image search, Instagram, Pinterest or anywhere else you've seen hair you admire.
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Image Field
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Image Field
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Based upon Andréa's Service Menu, what Services and/or Experiences are you thinking you may need?Please check all that apply
Personal Shopping Experience
Consultation
Wellness Massage
Detox Scalp Scrub
Rebuilding Hair Treatment
Rebuilding with Infrared Remedy Iron
Flower Fall Rinse
Hair Growth Treatment
Scalp Treatment
Infrared Amethyst Bio Mat
Women Haircut
Men Haircut
Children Haircut
Quick Don't Get Sick Blow Dry
Blow Dry Style
French Blowout
Iron Styling
Special Occasion Style
The Selfie Look Hair Color
The Root Hair Color
The Full Head Hair Color
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Your hair history within the last 3+ years.
I have colored my own hair.
I have not colored my hair in 3+ years.
I have gotten my hair colored professionally.
Other
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What hair color/product did you use? Please Check all that apply.
From Sally's Beauty Supply
From Online
From Drugstore/Grocery Store
Box Dye
Madison Reed
Splat
Overtone
Temporary Hair Color Rinse
Other
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Do you experience any discomfort during or after you color your hair?Drop down Selection
Please Select!
Please Select!
Yes, during
Yes, after
Yes, during and after
No
Please Select One
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What are you looking to get done?
Huge
Large
Normal
Small
Ok
Ok
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Is there anything else you'd like to share?
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Small
Ok
Ok
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