intake-form | Freequency Skin Care

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Occupation/ Daily Routine

Any known allergies? (Herbs, plants, essential oils, topicals)

What brought you to seek holistic guidance in your wellness routine?

When trying to focus or be present ( working out, stretching, resting,) how often does your mind drift?

Rarely

Often

At all times

When your mind drifts, where does it go? (Stress, to-do lists, past events, worries etc.)

What do you currently do to bring your focus back, if anything?

Why are you choosing to focus on your mind body connection and recovery, right now?

What has made it difficult to improve this area before?

What would change in your life if your mind body regulation, felt balanced consistently?

Are you open to adding recovery herbal practices (bath blends, breath work, affirmation, journal prompts?) to your sessions?

Are you willing to continue independent practice outside of sessions?

What will help you stay consistent with your routine?

Which program are you applying for?

Single Recovery Session

6 Week Nervous System Reset Program

12 Week Holistic Personal Training

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature

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The Freequency Method Intake