New Client Intake

Session Intake Form

Welcome. Please complete the form below before your Womb Light & ASMR Hair Harmonization session. It takes about ten minutes, and it helps Nicole hold a session that is truly yours.

Confidential — visible only to Nicole

Step 1

Your Information

So we know who we're welcoming and how to reach you.

Full Name*

Email Address*

Phone Number

Physical Address

Date of Birth

Preferred Contact Method

Occupation

How did you hear about us?

Emergency Contact Name

Emergency Contact Phone

Step 2

Your Session

Tell us which session you're drawn to and what you're hoping for.

Which session are you interested in?*

Is this your first session with us?

If returning, how many sessions have you had?

What would you like to receive from your session? (goals & intentions)

Step 3

Health & Wellness Screening

This helps us hold a safe space for you. Everything you share stays confidential.

Current or past health conditions

Medications or supplements you take

Allergies or sensitivities (scents, oils, products, materials)

Recent surgeries, injuries, or medical procedures

Pregnancy / postpartum status

Are you currently receiving mental health support?

Step 4

Hair & Scalp

A few details so your hair harmonization is tailored to you.

Before your session: please arrive with your hair clean, dry, and brushed through. No styling products needed — this helps the harmonization flow smoothly and uninterrupted.

Hair type & current length

Scalp conditions (dryness, sensitivity, psoriasis, etc.)

Recent hair treatments (color, keratin, extensions) and dates

Anything you'd like us to know about your hair or scalp?

Step 5

Comfort & Preferences

Your session should feel entirely yours.

Scent sensitivity

Touch sensitivity

Sound & environment preferences

Anything else you'd like us to know?

Step 6

Consents & Agreements

Please read each item carefully. Items marked with an asterisk are required.

Consent to Services *I consent to receive Womb Light energy work and ASMR hair harmonization from Nicole Obenshine of Integrative W.O.M.B. Techniques.Educational & Recreational Purposes Only *These sessions are for relaxation and education only — not medical, psychological, or therapeutic treatment, and not a substitute for a licensed provider's care. No diagnosis or cure is offered.Assumption of Risk & Limited Liability *I understand the nature of these sessions and participate voluntarily. I release Integrative W.O.M.B. Techniques, Nicole Obenshine, and their agents from claims or damages arising from my participation, to the fullest extent permitted by law.Terms & Conditions *I have read and agree to the terms of service, including booking, cancellation, rescheduling, and payment policies.Filming ConsentI consent to being filmed during my session.Photography ConsentI consent to photographs being taken during my session.Social Media & Marketing UseI allow photos or videos from my session to be used on social media and in marketing. I may withdraw this at any time by contacting Nicole in writing.

Typed Signature (type your full name)*

Date*

Social media handle (optional, so we can credit you)

Your responses are kept confidential and are only used to prepare for and support your sessions.