Lucky Girl Wellness Consultation Intake Form

Name*

First NameLast Name

Email*

Confirmation Emailexample@example.com

Address*

Street Address

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CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

1. What is your primary reason for seeking our services?*

2. How long have you been experiencing hair loss or damage?*

Less than 3 months3–6 months6–12 monthsOver a year

3. What areas of your scalp or hair are most affected?*

Front hairline or edgesCrown areaOverall thinningBald patches

4. Do you currently use any of the following?*

Wigs or hairpiecesProtective styles (e.g., braids, weaves, or twists)Chemical treatments (e.g., relaxers, perms, or color)Heat styling tools (e.g., flat irons, blow dryers, or curling wands)None of the above

5. How would you describe your hair and scalp condition?*

Dry and brittleOily or prone to buildupSensitive or itchyNormal

6. Are you currently experiencing any of the following medical conditions that may affect your hair or scalp?*

7. Are you currently taking any medications or supplements?*

Medications for hair loss (e.g., minoxidil, finasteride)Hormonal treatments (e.g., birth control, hormone replacement therapy)Multivitamins or hair supplementsOther (please specify): _____________

8. Do you feel Fatigued, have Anxiety or feel Depressed if so which one?*

FatiguedAnxietyDepressedAll the above

9. Are you experiencing any of the following symptoms?*

10. Have you recently experienced any of the following life changes?*

11. Have you ever been tested for any nutrient deficiencies (e.g., iron, vitamin D, B vitamins)?*

Yes, and I have a deficiency.Yes, but the results were normal.No, I have not been tested.

12. Do you have any history of scalp infections or skin conditions?*

13. How often do you wash and care for your hair/scalp?*

DailyEvery 2–3 daysWeeklyLess often

14. Have you consulted with any healthcare professionals about your hair loss or damage?*

Yes, a dermatologistYes, a primary care physicianYes, another specialist (please specify): _____________No

15. How did you hear about our services?*

Front Hair Line Right *

Front Hair Line Left*

Back Hair Line Right

Back Hair Line Left

Upload Crown (Hair Loss Clients Only)*

Please Take A Picture of Your Tongue ( Internal Wellness Purposes)

Consultation Guidelines and Expectations:

Welcome to Lucky Girl Wellness Session! Below, you’ll find the guidelines and expectations for your upcoming 90 minute wellness session. This session is designed to support your health journey by addressing your unique needs and goals.

What to Expect:
Duration: Consultations will last approximately 15 minutes Virtuial, and 90 minutes in person. The discovery call will give us a chance to understand your specific concerns regarding your health, hair growth, and wellness. During this call, you’ll be able to share your current lifestyle, challenges, and goals, and I will explain the session's structure and benefits.

Once your discovery call is complete, you’ll schedule your in-person coaching & wellness session. This part of the session focuses on understanding your body, emotional wellness, and current hair health through a series of personalized tests, consultations, and holistic practices.

We wil host different Holistic Practices to help determine the root cause of Hair Loss please see the following Practices:

Otoscope of Eyes (If Needed): Eye exam to identify signs of nutrient deficiencies, hormonal imbalances, or other health concerns affecting your wellness and hair health.

DermaScope of Scalp: Scalp and hair follicle analysis to check for thinning, dryness, or inflammation that may hinder hair growth.

Bach Flower Consultation: A holistic consultation to address emotional stressors and imbalances that impact hair and wellness.

Muscle Response Testing (MRT) (If Needed): Testing to identify areas of imbalance or stress in the body that could affect your health and hair growth.

Physical Observations & Charting: Visual examination of physical signs like your tongue, nails, and facial features to detect nutritional deficiencies or imbalances affecting your hair and overall health.

Zyto Testing: Utilizing the Zyto Compass technology, this biofeedback system helps identify stressors, imbalances, and areas of concern within the body. Zyto testing reveals underlying factors that could affect your wellness and hair growth, offering specific recommendations for supplements, products, and lifestyle changes to improve health.

pH Balance Test: A simple yet effective test to assess the acidity or alkalinity of your body. Understanding your pH balance can shed light on your digestive health, immune function, and even hair vitality. A balanced pH is essential for nutrient absorption and overall wellness.

Bristol Stool Charting: An evaluation of your digestive health through the Bristol Stool Chart, which helps identify patterns of digestion and elimination. This chart assesses whether your stools are too hard, soft, or lacking in consistency, providing insight into your gut health, which can impact nutrient absorption and overall well-being, including hair and skin health.

Based on your assessments, I’ll craft a personalized plan that includes specific lifestyle changes, stress-reduction techniques, nutrition tips, and strategies to support hair growth.

Based on your scalp and hair analysis, you’ll receive personalized recommendations for hair care products, including shampoos, conditioners, treatments, and serums that suit your needs.

I’ll provide suggestions for high-quality supplements to address any deficiencies found during testing, supporting overall health and hair growth.

After your session, you will also receive a detailed Zyto report via email, offering insights into imbalances or stressors in your body and offering specific solutions, including product and supplement recommendations.

In addition to the assessments, you’ll receive an educational lecture focused on hair health, stress management, and nutrition. This lecture will provide valuable insights and actionable steps to support your overall wellness journey.

During the session, we’ll dive into personalized coaching to guide you through understanding the changes you need to make for better health and improved hair vitality. I will answer all your questions and offer practical tools to implement in your daily routine.

As part of your session, you’ll receive a free eBook featuring recipes and tips on incorporating a raw food diet to improve nutrition and promote healthy hair growth.

You’ll receive a wellness gift tailored to support your hair and health, such as natural hair care products, essential oils, or herbal supplements.

Consultation Fee /Policies
The consultation fee is $185 and is non-refundable. This payment secures your scheduled sessions and ensures the resources provided are tailored to your needs.

Included Resources:

Free eBook: You will receive our exclusive eBook, Starting a Healthy Raw Diet. This guide provides practical tips and recipes to help you transition to a healthier lifestyle.

Sample Supplement Kit: As part of your consultation, you’ll receive a sample kit to introduce you to high-quality supplements tailored to support your wellness journey.

Confidentiality: All information shared during the consultation will remain confidential and used solely for providing personalized care and recommendations.

Do you understand the guidelines and timeline and agree to move forward with your 90 minute wellness Session?*

Yes, I understand and would like to move forward.No, I do not agree to the guidelines.

Appointment*

My Products*

Wellness SessionWellness Reservation with Coach Chardae Hureskin, CHHP, HLPC

$185.00 Quantity

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Lucky Girl Health& Hair Wellness Consultation

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