The Melanated Experience by Wealthy Place

New Client Intake

The room is built from your answers. Take three minutes and answer honestly. Nothing you write here leaves this room.

Section 1

Who you are

Full name *

What you want to be called in the room *

Phone number *

Email address *

Best way to reach you *

Age *

City and state *

Emergency contact name *

Emergency contact phone *

Who sent you here, or the number on your gold card if you were given one

Section 2

Your session

Date you booked

Time you booked

Which did you book? *

Where? *

Is this your first time? *

Section 3

Food, tea, and allergies

This section is required. The room is built from what you tell us here.

List every food allergy you have

Do you have a nut allergy, and if so which nuts?

Any allergy or reaction to olive oil, coconut oil, or avocado oil? We use those three oils only.

Any allergy or sensitivity to live plants, pollen, fragrance, or incense? Living plants including golden pothos and ferns are in the room and at your feet.

Any skin sensitivity or reaction we should know about

Foods you cannot eat for any reason, including religious and dietary

Fruits you love. Pick all that apply.

Teas you love, or tell us if you do not drink tea

What is your comfort meal? Name the food that makes you feel taken care of. *

Anything you absolutely do not want served to you

Section 4

The room we build for you

Music that moves you. Artists, genres, or specific songs. *

What do you want in the room? Pick all that apply.

Do you like the room warm or cool? *

Do you want the lights low or bright? *

Anything that helps you relax that we would not think to ask

Section 5

What you are carrying

What made you finally book this session? *

Which of these is heaviest for you right now? Check all that apply.

Where do you hold your stress in your body? *

Is there any part of your body you do not want touched?

What do you want to walk out of that room with? *

Is there anything you need us to handle with extra care?

Have you ever received bodywork or restorative work before? *

Section 6

The camera

Are you interested in sharing your story on camera with Channel 111 Media for the discounted series rate?

Section 7

How to come

Each item below is required. Check each one to confirm.

Signature

Type your full name as your signature *

Today's date