SPAAH Day Form
Your visit should be as stress free as possible. Completing this form will allow me to get to know the client and provide them with the best possible experience.
Name of Individual Completing Form
First Name
Last Name
Relationship to Client
Self
Parent
Spouse
Caregiver
Other
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Email
Phone Call
Text Message
Dates/Times Preferred
Tuesday Morning (10am-12pm)
Tuesday Afternoon (12pm-4pm)
Saturday Morning (10am-12pm)
Request Alternate Time
My preferred day is
blank
. My preferred time is
blank
.
Please list any food or environmental allergies:
Please list favorite snacks and drinks:
Please name favorite animal and favorite color:
Please describe any sensory struggles (i.e. light, sound, touch, messy play):
Please list any proven calming activities (i.e., fidget toys, tablet, etc.):
Is this a first haircut?
Yes
No
Does the client like to get their hair washed in the sink?
Yes
No
Sometimes
I don't know
Does the client tolerate clippers?
Yes
No
Sometimes
I don't know
N/A
Does the client have a difficult time sitting for a period of time longer than 5 minutes?
Yes
No
Sometimes
I don't know
Would you like to schedule a zoom call or salon tour with the client prior to the appointment? This can ease the anxiety of coming into a new place for many individuals.
Zoom
Salon Tour (while salon is closed)
Not Sure
No thank you
Does the client use a walking device or wheelchair? Please note that the salon is not wheelchair accessible at this time. Please contact the salon so we can help you further.
Yes
No
Yes but can make it up 4 steps to the salon with the caregiver's assistance
I will call the salon for further assistance.
Please add anything that you feel may be helpful for the appointment:
Submit
Should be Empty: