Which accessibility requirements do you have, if any?

Please select all that apply to you. Skip this question if none apply. If you select "other," please ensure you add in details for the follow-up question.

Latex Allergy

Scent Sensitive

Visually Impaired

Hearing Impaired

Mobility Impaired

ESL / English Second Language

Neurodivergent

Other

Which date are you requesting? *

Please note I no longer take clients on Wednesdays.

MM

DD

YYYY

What time are you requesting? *

Please note: my hours are from 12pm (noon) - 8pm.

Hour

Minute

Second

AM PM

Do you confirm that all the information you have provided on this form is accurate and true? *

It is against my terms to assume a false identity to procure services. Please ensure you are being honest and trustworthy, as I would be with you. ALSO: please double check that you have filled this form out correctly (especially your contact information), otherwise I may not contact you.

Yes

No

Do you confirm that you have read, understood, and agreed to all of the Terms of Service listed on the Policies page? *

If you do not agree with the TOS, please do not use these services. Please contact me directly if you have any questions. These are the key points from the TOS: - You will behave in a respectful, trustworthy, and considerate manner, and openly communicate about your preferences and any appointment changes. - You will ensure any deposits and payments requested and/or required by Monica will be paid on time. Full payment is due at the start of session. - You will be free of any active or transmittable infection, and not require urgent medical care at the time of your appointment. - You understand that if you cancel within two hours of your appointment time, you owe a $50 cancellation fee. This is the same for no shows. - You understand that Monica will protect and treat all your personal information and interactions with her as confidential unless legal action is required. - You understand that you waive any and all claims of liability against Monica when using her services (note: Monica will do her best to ensure your health and safety). - You understand that you have the right to end a session or terminate services at any time, for any reason. Monica may do the same without justification. - You understand that services will be discontinued or denied if you engage in conduct outside of your agreement or attempted without prior consent.

Yes

No