Essential Oil Therapy Client Intake
and Assessment Form

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Below is a detailed breakdown of the Essential Oil Therapy Client Intake and Assessment Form, including its purpose, structure, and the reasoning behind each section and question. This form is designed to ensure a safe, personalized, and effective aromatherapy experience for the client.

Purpose of the Form

The primary goal of this intake form is to:

• Gather essential information about the client’s health, lifestyle, and preferences.
• Assess suitability for aromatherapy and identify any potential contraindications.
• Customize the therapy to meet the client’s specific needs and goals.
• Ensure safety by identifying allergies, sensitivities, or medical conditions that may affect the use of essential oils.
• Build trust and rapport by understanding the client’s expectations and concerns.

Detailed Insights into Each Section

Section 1: Personal Information

Purpose: To establish basic client details and ensure proper communication.

Key Questions:

• Full Name & Date of Birth: Helps personalize the therapy and track client records.
• Gender: Some essential oils may have gender-specific effects (e.g., hormonal balance).
• Contact Information: Ensures the therapist can follow up or share the custom blend.
• Emergency Contact: A safety measure in case of adverse reactions.

Section 2: Health History

Purpose: To identify any medical conditions, allergies, or sensitivities that could affect the safety or effectiveness of aromatherapy.

Key Questions:

• Allergies: Essential oils can trigger allergic reactions in some individuals.
• Medical Conditions: Certain conditions (e.g., epilepsy, high blood pressure) may contraindicate specific oils.
• Medications: Some oils interact with medications (e.g., blood thinners).
• Skin Sensitivities: Essential oils must be diluted properly for topical use to avoid irritation.
• Pregnancy/Breastfeeding: Some oils are unsafe during pregnancy or lactation.
• Adverse Reactions: Helps avoid oils that may have caused issues in the past.

Section 3: Lifestyle and Preferences

Purpose: To understand the client’s goals, preferences, and daily habits, which influence the choice of oils and application methods.

Key Questions:

• Primary Goals: Identifies the client’s intentions (e.g., stress relief, sleep improvement).
• Stress Levels & Sleep Quality: Helps tailor the blend to address specific concerns.
• Scent Preferences: Ensures the blend is enjoyable and effective for the client.
• Preferred Application Method: Determines how the client will use the oils (e.g., diffuser, topical, bath).

Section 4: Aromatherapy Suitability

Purpose: To assess the client’s experience with essential oils and address any concerns.

Key Questions:

Previous Experience: Helps the therapist understand the client’s familiarity with aromatherapy.

• Concerns: Addresses any fears or reservations the client may have.
• Openness to New Blends: Determines if the client is willing to try new oils or prefers familiar scents.
• Spiritual/Cultural Preferences: Ensures the therapy aligns with the client’s beliefs or practices.

Section 5: Custom Blended Essential Oil Therapy Options

Purpose: To guide the therapist in creating a blend that aligns with the client’s needs and preferences.

Key Questions:

• Type of Therapy: Allows the client to choose from pre-defined blends or request a custom blend.
• Organic/Sustainable Preference: Caters to clients who prioritize eco-friendly or natural products.
• Consultation Preference: Gives the client the option to discuss the blend before it’s prepared.

Section 6: Consent and Agreement

Purpose: To ensure the client understands the scope of aromatherapy and agrees to the terms of service.

Key Points:

• Not a Substitute for Medical Treatment: Clarifies that aromatherapy is complementary, not a replacement for medical care.
• Permission to Create Blend: Formal consent to proceed with the therapy.
• Patch Test Recommendation: Encourages safety by testing for skin sensitivity.
• Responsibility to Inform Changes: Ensures the therapist is updated on any health changes that may affect the therapy.

Why This Form is Comprehensive

• Safety First: The form prioritizes client safety by identifying potential risks (e.g., allergies, medical conditions).
• Personalization: It gathers detailed information to create a truly customized blend.
• Client-Centered: The form empowers clients to express their preferences and concerns.
• Professionalism: It establishes clear boundaries and expectations, fostering trust between the client and therapist.
• Legal Protection: The consent section protects both the client and therapist by outlining responsibilities and limitations.

How Therapists Use This Information

• Blend Creation: The therapist selects oils based on the client’s goals, preferences, and health history.
• Application Guidance: The therapist recommends the best method of use (e.g., diffusion, topical application).
• Contraindication Avoidance: The therapist avoids oils that may be unsafe due to allergies, medications, or medical conditions.
• Follow-Up: The therapist uses the contact information to check in with the client and adjust the blend if needed.

Example Scenario

A client fills out the form and indicates:

• Primary Goal: Stress relief and improved sleep.
• Health History: Allergic to nuts (avoid carrier oils like sweet almond oil).
• Preferences: Dislikes strong floral scents, prefers citrus and woody aromas.
• Application Method: Prefers diffusion.

The therapist creates a blend using:

• Essential Oils: Bergamot (citrus, calming), cedarwood (woody, grounding), and lavender (mild floral, promotes sleep).
• Carrier Oil: Fractionated coconut oil (nut-free, safe for topical use if needed).

This form ensures that the therapy is safe, effective, and tailored to the client’s unique needs, resulting in a positive and healing experience.