Name or Nickname
*
First Name
Last Name
Pronouns
*
Email
*
example@example.com
How were you referred?
*
Please Select
Instagram
Reddit
Website
Friend
Other
Other
What do you LOVE about your hair and scalp?
*
What are some challenges or wish you could change about your hair and scalp?
*
How much time are you willing to invest on your hair and scalp care each day?
*
Please Select
5 min
10 min
15 min
As much as it takes!
What are you currently experiencing with your hair and scalp?
*
Feel Incredible
Feels Brittle
Feels Damaged and Defeated
Fuzzy/Frizzy
Dull/Lacking Shine
Flat/No Volume or Texture
Thinning
Hair Recession
Oily Scalp
Dry Scalp
Itchy Scalp
Red Scalp
Briefly describe how long you have been experiencing scalp challenges?
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Off and on my whole life
Seasonally
When I switch products
I feel like its always irritated
Do you wear extensions?
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Yes
No
If yes, what kind and for how long?
*
Please list anything you have used to alleviate your scalp irritation.
*
Ex: Head and Shoulders, Scalp Oils, Scalp Scrubs, Etc.
Are there any essential oils you'd like to stay away from or allergies I need to be aware of?
*
Ex: Lavender, Rosemary, Eucalyptus, Citrus, Etc.
Are you sensitive to Peppermint or Eucalyptus (a cooling sensation) on your scalp?
*
Have you ever seen your scalp on a microscope?
*
Yes
No
What is relationship with your blowdryer like?
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I don't have a blowdryer
I use a blowdryer every time I wash my hair
I exclusively air-dry
I partially air-dry then follow up with a blowdryer to style
50% I just air-dry and 50% I am blowdrying
other
If you checked other, please describe below.
*
How big is the circumference of your ponytail?
*
Hair is too short for a ponytail
Less than a dime size
Dime-size
Nickel size
Quarter size
Bigger than quarter size
unsure
Please upload a recent photo of your hair here. (10/10 recommend a silly selfie)
*
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Are you currently on any medications or supplements? (DISCLAIMER: I understand that this is personal so please know that information remains completely confidential. New medications and supplements can have a huge effect on our hair and scalp health, this will help me get to the root cause of your challenges.)
*
If you aren't on anything, simply write, N/A.
How long have you been taking your medication or supplements?
*
If you aren't on anything, simply write N/A
Would you like to infuse an intention into our vision/session?
*
EXAMPLE: "I release stress and invite peace and balance into my life."
Would like energy healing incorporated into your head spa experience?
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I would love that!
Maybe next time!
Are you desiring a haircut with your scalp facial?
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Yes
No
If yes, please drop any inspo pics here!
*
Browse Files
Drag and drop files here
Choose a file
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Please take a moment to express anything I haven't touched on or would like me to know? (I welcome love notes as well!)
Submit
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