Appointment Request Form
Let's get started!
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What date and time work best for you? (Request only)
Any other specific date and time, if the above selection is not suitable.
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
How did you hear about me? If it was a referral, please list their name! (Please specify if you were referred by Family Providence Life Center)
*
What service(s) are you interested in?
*
Please Select
Therapeutic Full-body Massage (60 min)
Therapeutic Full-body Massage (90 min)
Therapeutic Full-body Massage (120 min)
Lymphatic Drainage (NOT full body (60 min))
Lymphatic Drainage & Full-body Massage (90 min)
Lymphatic Drainage & Full-body Massage (120 min)
Deep Tissue (NOT full body (60 min))
Deep Tissue & full body massage (90 min)
Deep Tissue & full body massage (120 min)
Sensory Relaxation Session (30 min add-on)
Sensory Relaxation Session (60 min)
Sensory Relaxation Session (90 min)
Peaceful Presence Massage (60 min)
What is your goal for our first session?
*
Please Select
Relaxation
Pain relief (general tension, minor injuries)
General maintenance
Injury/chronic issue (deep tissue)
Please explain a little bit about what you are looking for in our session. This may include pressure preference, areas of pain/tension, injuries, areas to avoid, preferred techniques, and/or anything else you want me to know!
*
Do you need any special accommodations? This may include off-table massage (in chair or bed), flexible session times, extra assistance on and off the table, alternative draping methods, fully clothed massage, weighted blankets, caregiver (or other) present, supine/prone only, extra support with pillows, etc. If yes, please explain.
*
What is your experience with massage/bodywork? Is this your first time, have you received it regularly in the past, any negative experiences, or any other things you would like to ask or talk through?
*
Is there anything I need to know BEFORE I drive to your home? This may include gate codes, stairs/elevators, pets, etc.
*
Talking preference?
*
Please Select
No talking
Let's chat!
Music preference?
*
Please Select
Ambiant (default)
Your own playlist
None
Other
Would you like guided meditation/breathing?
*
Please Select
Yes
No
Would you like aromatherapy (essential oils)?
*
Please Select
Yes
No
Would you like sound therapy (singing bowl)?
*
Please Select
Yes
No
Any add-ons?
*
Please Select
Extra 15 min ($25)
Cupping ($25)
Hair oiling ($40)
None
Anything else I can do to make this session perfect for YOU?
*
Would you like to be notified about promotional services?
Yes
No
Thank you for your thoughtful answers!
After you click submit, you can expect a reply from me within 12-24 hours. We will then confirm the appointment date/time and move forward with intake forms and payment. Email me if you have any other questions! (bellasattva.love@gmail.com) *Appointment is NOT confirmed until intake forms are completed & signed*
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