Client Intake Form

Client Intake & Product Guidance Form

These questions help me understand your cycle, symptoms, and energetic patterns so I can guide you toward the products that will support your body most deeply. Please answer whatever you feel comfortable sharing.
Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cycle & Hormonal Rhythm 1. Do you currently have a menstrual cycle?

Irregular 2. If yes, what is the average length of your cycle? Last 3 cycle dates?
1. Do you currently have a menstrual cycle?
2. If yes, what is the average length of your cycle? Last 3 cycle dates?
3. Are you currently experiencing any of the following?
4. What phase do you feel most supported... and least supported?
5. Do you experience:
6. What emotions have been most active lately?
7. Do you feel more:
8. How is your sleep?
9. Do you experience:
Womb tension or pelvic heaviness

Heart heaviness or emotional tightness in the chest Burnout or adrenal fatigue symptoms

Bloating around luteal phase 10. Have you had any recent infections (yeast, BV, UTI, etc?
10. Have you had any recent infections (yeast, BV, UTI, etc.)?
11. Do you take time for daily grounding or ritual? If so, what does that look like?
12. Do you do any creative projects, dance, sing, and/or workout?
13. What results are you hoping for in the next 1–3 months?
14. Anything else you'd like me to know about your body, emotions, or current healing season?
15. Are you pregnant or breastfeeding?
16. Are you on any medications or have allergies?
Should be Empty: