Client Intake Questionnaire

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

What is your main hair or scalp concern?* This field is required.

Hair Loss

Scalp Issues (itchiness, flaking, irritation)

Hair Damage (breakage, split ends, dryness)

General Maintenance/Wellness

5

Please describe your hair loss experience (e.g., duration, areas affected, any treatments tried).

Less than 3 months

3–6 months

6–12 months

More than 1 year

Not sure

Other

6

Please describe your scalp issues (e.g., symptoms, duration, triggers, any treatments tried).

Itchiness

Flaking or dandruff

Irritation or redness

Dryness or tightness

Oiliness or buildup

Other

8

What are your goals for hair maintenance or wellness?

Reduce hair loss

Improve scalp health

Repair damage

Improve hydration and softness

Support hair growth

Other

9

What are you currently experiencing with your hair or scalp?

Increased shedding or thinning

Scalp irritation, dryness, or buildup

Gray regrowth or wanting softer, more natural coverage

Gray regrowth want complete coverage, more consitstant routine

Hair feels dry, damaged, or lacking shine

I feel overwhelmed, stressed, and need time to relax

I want a more natural, low-tox maintenance routine

Other

10

How would you like your hair to feel?

Fuller and stronger

Clean, balanced, and refreshed

Softly blended and natural-looking

Smooth, hydrated, and shiny

Light, calm, and cared for

Naturally healthy and easy to manage

Other

11

What kind of experience are you craving right now?

Targeted support for a specific concern

A reset or detox

A natural, graceful color refresh

Deep repair and nourishment

A quiet, calming escape

Ongoing, consistent self-care

12

How important is a low-tox, eco-conscious approach to you?

Extremely important- I actively seek it out

Important, but I'm still learning

I'm open to it if it supports my results

13

How often do you typically invest in hair care?

Every 4-6 weeks

Every 6-10 weeks

Only when I feel like I really need it

I'm ready to be more consistent