Client Intake Information

CLIENT INTAKE INFORMATION
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
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.
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CLIENT INTAKE INFORMATION