Client Intake Form Your skin holds your story. Let’s listen with care. Name * First Name Last Name Email * Birthday * MM DD YYYY Phone * (###) ### #### How did you hear about Lügn Esthetics? Google, Instagram, Friend, Family? (please state the name of the person who referred you) * How does your skin feel on most days? * Dry Oily Dehydrated Congested Sensitive Dull Inflamed Balanced What are your top 1-3 skin concerns right now? * Fine lines / aging Puffiness / stagnation Hyperpigmentation / spots Breakouts / acne Texture / roughness Redness / sensitivity Lymphatic sluggishness Energetic imbalance / emotional stress What would you love to experience through skincare? * A moment of peace + deep relaxation A visible skin transformation Long-term maintenance + glow A little of everything What have you tried in the past for your skin? * Have you received holistic or energy-based therapies before? * Yes No How would you describe your current stress levels? * How many hours of sleep do you get nightly? What's your water intake like? Are you currently on any medications (topical or internal) related to skin or hormones? What is your ideal goal for your skin + self-care? Which Skin Journey Phase do you feel drawn to (if any)? RESET & RECEIVE - I need nervous system + skin calming REVEAL & RENEW - I'm ready to correct + glow up RITUAL & RADIANCE - I want long-term maintenance and balance Not sure - guide me! What is your skincare budget (for services and/or at-home support)? Under $100 $100-$200 $200-$300 $350 + I'm open to packages if it helps me reach my goals faster Would you be interested in: (check all that apply) Memberships or Monthly Rituals Multi-session packages or series At-home tools or curated kits Energy healing or somatic add-ons Just a one-time facial for now Are there any physical or emotional concerns I should know about to help create a safe and supportive experience? Any upcoming events or timelines I should know about? Are you pregnant or breastfeeding? Do you have any allergies or sensitivities? Would you like to receive a customized skin journey recommendation or at-home ritual suggestion after your appointment? Yes please! No thank you I understand that Lügn Esthetics offers holistic and corrective skincare within a trauma-informed space. I agree to communicate openly, respect boundaries, and honor the cancellation policy. I agree I have questions Thank you!
