SP

SATINEPhoenix

HEALTH COACH
REFLECT  ·  REBUILD  ·  RISE
Health Optimization
Coaching CLIENT INTAKE FORM

Welcome

Your Story is the Starting Point
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Thank you for choosing to work with me. This intake helps me understand where you are now, where you want to go, and how we can work together safely and effectively.

Please complete each section as fully and honestly as you can — everything you share is treated as confidential.

The Basics

1. Client Information

Full Legal Name
Date of Birth
Pronouns
Email
Phone
City and State
Time Zone
Best Time to Reach You
How Did You Hear About Me?
Emergency Contact Name
Emergency Contact Phone
Where You Are Now

2. Health Background

Reminder: I am not a licensed medical practitioner and this is not a medical intake. Please share what you're comfortable with so we can work together safely.

Are you currently under the care of a physician or specialist?
If yes, briefly describe (condition, provider type)
Current Prescription Medications (name, dose, reason)
Current Supplements, Vitamins, Hormones, or Peptides
Known Allergies or Sensitivities (medication, food, environmental)
Significant Medical History (chronic conditions, surgeries, hospitalizations)
Are you pregnant, nursing, or actively trying to conceive?
Any history of cancer (personal or first-degree relative)?
Any history of heart disease, blood-clotting, or stroke?
Any history of mental-health concerns currently being managed?
What You've Tried

3. Peptide and Supplement Experience

Have you used peptides before?
If yes, which peptides, doses, and how long
What outcomes (positive or negative) did you experience?
Are you currently using any peptides?
If yes, list current peptides and current dosing
Daily Rhythm

4. Lifestyle Snapshot

Activity Level
Tell me about a typical week (workouts, walks, sports, etc.)
Sleep Quality (1 = poor, 10 = excellent)
LowHigh
Average hours per night, sleep issues, bedtime routine
Stress Level (1 = low, 10 = very high)
LowHigh
What's contributing to current stress? How do you manage it?
Energy Level (1 = depleted, 10 = vibrant)
LowHigh
When is your energy highest / lowest? Any patterns?
Water Intake (typical day)
What do you drink (water, electrolytes, coffee, tea)? Any patterns?
Dietary Approach (e.g., omnivore, vegan, low-carb, intuitive)
Alcohol Use (frequency)
Tobacco / Cannabis / Other (if any)
Where You're Going

5. Goals and Intentions

What is your primary intention for working together?
Secondary goals or areas you'd also like to address
Why is this a priority for you right now?
What does success look like in 30 days?
What does success look like in 60-90 days?
What have you tried before? What worked? What didn't?
How We'll Work Together

6. Expectations of Our Engagement

What do you expect from a coaching relationship with me?
Preferred Communication Channel
Best Phone / Email / Handle to Reach You
Desired Check-In Cadence
Day / Time of Day That Works Best for You
What would make this engagement a clear success for you?
The Real Work

7. Commitment and Obstacles

Are you ready to commit to consistent practice between sessions?
What's most likely to get in the way? (time, travel, mindset, etc.)
Who in your life is supportive of this work? Anyone unsupportive?
One Last Thing

8. Anything Else

Anything else you'd like me to know before we begin?
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Acknowledgment

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that Satine Phoenix is not a licensed medical practitioner, that health optimization coaching is educational and not medical care, and that I am responsible for consulting a qualified physician about any medical decision. I have signed (or will sign) a separate Liability Waiver and Informed Consent.

Client
Printed name
Signature (type your full name)
Date (MM/DD/YYYY)

Send Your Intake Form

A copy is automatically sent to the email you entered above and to Satine.
Trouble submitting? Email your filled details to stonesatine@gmail.com.
✓

Thank you

Your intake form has been received. A copy is on its way to your inbox, and Satine will be in touch shortly to begin the work.

SATINE PHOENIX  ·  HEALTH COACH  ·  REFLECT. REBUILD. RISE.