AMARA™ CLIENT INTAKE QUESTIONNAIRE

This questionnaire supports a calm, safe, and personalized Amara experience. Please answer honestly and intuitively. Share only what feels comfortable. There are no right or wrong answers.

Client Information

Full Name:

Date of Birth:

Phone Number:

Email Address:

Emergency Contact & Phone:

Skin Health

How would you describe your current skin concerns or goals?

Are you currently using any skincare products or receiving professional treatments?

Have you experienced sensitivity, reactions, or allergies to skincare products?

Health Considerations

Are you currently under medical care or treatment? If yes, please share what feels relevant.

Have you recently undergone medical treatments that may affect your skin or energy levels?

Are you pregnant or nursing?

Yes No

Nervous System & Stress

How would you describe your current stress level?

Low Moderate High

Do you experience migraines, jaw tension, or chronic body tension?

How would you describe your sleep quality?

Emotional & Lifestyle (Optional)

Are you currently navigating emotional stress, grief, or a major life transition?

Is there anything you would like your practitioner to be aware of before your session?

Session Preferences

Do you prefer silent or quiet sessions?

Silent Quiet

Is there anything that helps you feel especially safe or comfortable during treatments?

Consent & Acknowledgment

Client Signature:

Date: