CONFIDENTIAL CLIENT INTAKE INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
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Day
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Month
Year
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Emergency contact Name and Phone number - CONFIDENTIAL AND FOR EMERGENCIES ONLY
*
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? *
*
For 2 hour plus sessions ONLY - would you like to have the use of a bed?
Are there any films, music or tv you would like?
Would you like to pay by Cash or free bank transfer?
*
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.
Date
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Day
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Month
Year
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Signature
Submit
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