Special Haircuts Intake Form

CLIENT INTAKE FORM
Complete the following Intake Form Prior to the Service

To make the experience as comfortable and enjoyable as possible for your child, please help us by filling out this form. Your insights are invaluable in providing a tailored, positive haircut experience.
Person Receiving Service:

First NameLast Name
Date of Birth (if under 21 years of age)*

MonthDayYear
Date
Guardian/Parent's Name (if applicable)

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Methods of Communication Used: (e.g. verbal, non-verbal)
Preferred Communication Techniques: (if any, such as prompts or visual aids)
What is helpful for holding the client's attention? (e.g. specific toys, videos, music)
Signs of Enjoyment/Contentment: (e.g. flapping, screeching, jumping up and down)
Signs of Anxiety/Discomfort: (e.g. rocking, covering ears, vocalizations)
Triggers or Sensitivities: (e.g. specific sounds, textures, or situations)
Calming Strategies: (e.g. breaks, quiet space, deep pressure)
Previous Haircut Experiences: (please describe, including any positive or negative reactions)
Haircut Preferences: (e.g. particular style, length, tools that are okay or not okay)
Additional Notes or Requests: (any other information that can help us make the haircut experience better for the participant)
I,blanks (Parent/Guardian Name), acknowledge that the information provided is accurate to the best of my knowledge and I consent to the services provided by Calhoun's Creative Cutz tailored to the needs of my child as described above.

Signature: Signature Date: Date
Should be Empty:

CLIENT INTAKE FORM

Complete the following Intake Form Prior to the Service