Sensory Sensitivity Intake

Sensory Sensitivity Intake
Client Information
Name

First NameLast Name
Age
Email
example@example.com
Phone Number

Area CodePhone Number
If you need assistance filling out this form, contact me at hairdesignbyruth@gmail.com or call/text 971-201-6586.

There are days/times that better accomodate your needs. This intake form helps me understand when to schedule you and how I can support you during your appointment.

*The information provided in the form is strictly confidential and will not be shared or sold to any third parties or social media platform. Your privacy and the security of your personal information are of utmost importance.*
Hair Intake
When was your last haircut?
How often do you like to get your haircut?
Do you want to spent time styling your hair?

YesA little timeNo
Do you use styling products?

YesNo
Tell me about your past experiences in salons. What things worked well or didn't work well in helping you feel comfortable and regulated?
Sensory Sensitivity Intake
Auditory (e.g. loud noises, background noise, blow dryers, music, electric clippers, conversation.)*

Not SensitiveSomewhat SensitiveVery Sensitive
Please specify on auditory sensitivities and supports or accommodations needed.
Visual (e.g., bright lights, glare on surfaces, crowded spaces)*

Not SensitiveSomewhat SensitiveVery Sensitive
Please specify on visual sensitivities and any supports or accommodations needed.
Tactile (e.g., certain textures, touch from another person, water, spray bottle, cutting tools, grooming tools, cape fabric, styling products, ingredient allergies.)*

Not SensitiveSomewhat SensitiveVery Sensitive
Please specify on tactile sensitivities and any supports or accommodations needed.
Olfactory (e.g. strong smells, hair products, essential oils)*

Not SensitiveSomewhat SensitiveVery Sensitive
Please specify on olfactory sensitivities and any supports or accommodations needed.
Is there anything else you would like me to know?
Thank you for sharing this information and requesting an appointment. I will contact you within 48hrs to schedule your appointment. I look forward to working with you!
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Sensory Sensitivity Intake

Client Information

Hair Intake

Sensory Sensitivity Intake