Client Intake Information

CLIENT INTAKE INFORMATION
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact Name and Phone number
Where did you hear about Heartfelt Healing?
Health & Wellbeing - Please briefly describe any physical or emotional health considerations you'd like me to know about:
Session Preferences - Do you have any preferences or boundaries around touch (e.g., positions, areas to avoid)?
Goals - What are you hoping to gain or experience through cuddle therapy?
Consent & Agreement
I understand that cuddle therapy is a non-sexual, fully clothed, platonic service. I agree to participate respectfully and communicate clearly. I understand I may withdraw consent at any time.
Signature
Date

MonthDayYear
Date
Should be Empty:

CLIENT INTAKE INFORMATION