PBHC Wellness Profile

WELCOME TO PEACE & BALANCE

This form helps us understand your wellness goals, sensitivities, and current state so we can create a session that truly supports you. Your information is confidential and used only to personalize your care.

If you have any questions while completing this form, feel free to reach out.

wellness@peacebalanceholistic.com

SECTION 1: General Information
Date
Full Name*

First NameLast Name
City, State, Country (if not USA)*
E-mail*
Phone Number/Text*
Emergency Contact*

First NameLast Name
Emergency Contact #*
Birth Date*

MonthDayYear

SECTION 3: Ayurvedic Bodywork & Therapeutic Massage
Do you prefer silence, mantras, soft music, or conversation during treatments?
Please list or include any oils, herbs or natural scents you prefer to avoid.*
i.e. palo santo, sage, essential oils, etc.

SUBMIT FORM
What are you interested in?

Therapeutic Massage SessionAyurvedic Bodywork SessionConsultationYoga / Meditation / Breathwork SessionsAyurvedic WorkshopsOther
Should be Empty: