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Reflexology Questionnaire - The Barefoot Optimist
*please take a few minutes to carefully complete this survey prior to being accepted as a new client

1.Full name and phone #(Required.)
2.How did you learn about Kimberley & The Barefoot Optimist?(Required.)
3.Have you experienced a reflexology session in the past?(Required.)
4.What inspired you to seek a reflexology experience?(Required.)
5.What are your current health & wellness goals?(Required.)
6.How are you currently approaching your health & wellness goals? For example, what practices, exercise, supplements, etc. are you choosing presently?(Required.)
7.Are you receiving care for any physical, emotional or mental health based conditions or challenges ? Yes/No and share details, please. Additionally, do you have any foot/leg based situations like injury, edema, eczema, warts, etc.?(Required.)
8.Please share:
any conditions currently diagnosed or symptoms being addressed and medications or supplements you are taking. (Can send email to kibbyjardine@gmail.com if you need more space...)(Required.)
DISCLOSURES:
1. The Barefoot Optimist (TBO) is currently seeking clients who wish to actively pursue improving their health & wellness and who choose to partner via intentional discourse and exchange. TBO will support clients via sessions and follow ups as they embrace positive changes and growth, mindset adjustments and overall improvement of physical health & mental/emotional well-being.
2. I understand that phones are to be powered off during a reflexology session and kept on silent in waiting room. (Or leave in car.)
3. I understand that each session is booked for either:
a. $85/one hour + 15 minutes
* includes 10 minute foot soak w/intake conversation, 50 minutes hands-on treatment, 10-15 minutes post session debrief.
b. $120/one hour + 45 minutes
* includes 10 minute foot soak w/intake conversation, 50 minutes hands-on, 45 minutes post session debrief + coaching session.
4. I understand that payment for a session is due at its completion. The Barefoot Optimist accepts cash or Venmo at this time. Checks are not accepted at this time unless prior arrangements are made.
9.By typing my full name below I acknowledge disclosures contained above and intend to arrive at my reflexology session prepared for an intentional healing partnership.

I recognize that a single reflexology session is part of a journey.

I also acknowledge that I will be charged for a no-show or session cancellation with less than 24-hours notice.(Required.)