Custom Product Order Form

1
Tell us what’s been going on for you lately, such as changes in your energy, sleep, digestion or stress. We’ll use your answers to choose herbs that fit your needs, sensitivities and routine.This takes about ten minutes and helps us thoughtfully formulate your blend. This form should be completed by the person who will drink the tea. If that isn’t you, please send them this form.
2
What signals have you been noticing in your body lately?* This field is required.Select all that apply (up to 5).
Stress or feeling overwhelmed
Anxiousness or nervous tension
Difficulty winding down
Trouble falling asleep
Waking during the night
Low energy or fatigue
Difficulty focusing
Headaches
Muscle tension or body aches
Inflammation or general discomfort
Unsettled digestion
Bloating or gas
Constipation
Loose stools
Nausea
Changes in appetite
Menstrual cramps
PMS or mood changes around my cycle
Irregular or changing cycles
Menopause or perimenopause changes
Skin irritation or breakouts
Seasonal discomfort
Throat or respiratory discomfort
Feeling run-down or needing immune support
Urinary discomfort
Pregnancy or postpartum changes
Breastfeeding-related support
Grief
Emotional heaviness
Other
3
Tell us a little more about what you selected.When did it begin? What does it feel like, and is there anything that makes it noticeably better or worse?
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4
What kind of support are you hoping to receive from your blend?* This field is required.Choose up to three.
Calm and nervous-system support
Deeper or more restful sleep
Steadier energy
Focus and mental clarity
Digestive support
Menstrual or hormonal support
Pregnancy or postpartum nourishment
Breastfeeding support
Skin support
Seasonal support
Immune nourishment
Inflammation support
Everyday mineral nourishment
Emotional comfort
I’m not sure—I’d like you to decide based on my intake
Other
5
Have you noticed any patterns in when or how these signals change?For example: noticing things change related to your hormonal cycle, the seasons, stress, sleep, certain foods, or anything else that seems connected.
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6
Is there anything about your daily routine that would be helpful for us to know?For example, your schedule, meals, movement or daily practices (optional).
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7
Are you currently pregnant, trying to become pregnant, or nursing?* This field is required.This helps us choose herbs that are appropriate for you. Select all that apply.
Pregnant
Nursing
Trying to become pregnant
None of the Above
8
Please list any medications or supplements you currently take.* This field is required.Include prescription and over-the-counter medications, hormonal birth control, vitamins, supplements and herbs. Add doses if known, or write “none.”
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9
Please list any diagnosed health conditions.* This field is required.Such as thyroid disorders, autoimmune conditions, high or low blood pressure, liver or kidney conditions, diabetes, or bleeding disorders, etc. Write 'none' if this doesn't apply.
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10
Please list any allergies, sensitivities or ingredients you need to avoid.* This field is required.Please include any foods, plants, or ingredients that have caused a reaction before (e.g., ragweed, chamomile, citrus, or other Asteraceae/daisy-family plants). Write 'none' if this does not apply.
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11
Which flavors do you enjoy in tea?Select all that apply
Floral
Fruity or tart
Citrusy
Minty
Earthy
Spicy or warming
Bitter
Naturally sweet
No preference
Other
12
Are there any flavors you strongly dislike or would like to avoid?
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13
When would you most likely drink your tea?
In the morning
During the afternoon
In the evening
Before bed
It varies/ no preference
14
Your name* This field is required.Enter the name exactly as you’d like it to appear on your blend label
First Name
Last Name
15
Email* This field is required.Please use the same email address you’ll use at checkout so we can match your intake to your order.
example@example.com
16
I confirm that* This field is required.The information I provided is accurate and complete to the best of my knowledge. I understand this tea is intended to support general well-being and is not a substitute for medical advice, diagnosis, or treatment, and I will consult my healthcare provider before use if I am pregnant, nursing, managing a health condition, or taking medication. I consent to Persephone Apothecary using the information I've provided to formulate my custom tea blend
I have read and agree to the statements above.
17
I’d like to receive Persephone Apothecary’s weekly notes on plants, body patterns, and supportive rituals, along with product news and offers.This won't affect your blend or order, and you can unsubscribe anytime
Sign me up!No, thank you
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