Client Intake Form — WellSourced Certified Practitioner
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WellSourced Certified Practitioner
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WellSourced
✦ WellSourced Certified Practitioner

Client Intake Form

Confidential — For Educational Consultation Use Only

Date: _____________________   Client ID: _____________

Practitioner Information
Practitioner Name:                               
Practice / Business:                             
Email:                                     
Phone / Website:                               
01 — Personal Information
First Name *
Last Name *
Date of Birth
Email Address
Phone
Location (City, State)
Referred by
Occupation / Industry
02 — Health Background

This information is used to tailor your educational consultation. This is not a medical intake form. Please consult a licensed physician for medical advice.

Age
Biological Sex
Do you currently work with a physician or healthcare provider? If so, in what capacity?
General health areas of focus (check all that apply)
Any known allergies, sensitivities, or relevant health history you'd like your educator to be aware of?
03 — Current Supplements & Protocols
Current daily supplements or medications (list all relevant):
Have you worked with peptides before? If yes, which ones?
How would you describe your research experience with peptides?
Where have you sourced peptide education previously?
04 — Goals & Priorities
Please rank your top 3 goals for this educational consultation (1 = highest priority):
  • ___ Learn which peptides support my specific health goals
  • ___ Understand how peptides work scientifically
  • ___ Learn about peptide sourcing, quality, and safety
  • ___ Create an informed protocol to discuss with my physician
  • ___ Understand stacking and synergistic combinations
  • ___ Ongoing accountability and education support
  • ___ Other: _________________________________________________
In your own words, what would a successful consultation outcome look like for you?
How would you rate your current energy levels? (1 = very low, 10 = excellent)
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How would you rate your current sleep quality? (1 = poor, 10 = excellent)
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05 — Logistics & Availability
Preferred contact method
Time zone
Preferred session days / times
How did you hear about this program?
Anything else you'd like me to know before our first session?
06 — Acknowledgment & Consent

Educational Scope of Service. I understand that the services provided by this WellSourced Certified Practitioner are educational in nature only. This consultation does not constitute medical advice, diagnosis, or treatment. The practitioner is not a licensed physician or healthcare provider (unless separately disclosed), and no client/patient relationship is established.


No Medical Claims. I understand that information shared during consultations is for general educational purposes and should not replace the advice of a licensed medical professional. I agree to consult a qualified physician before starting, stopping, or changing any health protocol, supplement, or peptide use.


Confidentiality. I understand that the information I provide in this intake form is confidential and will only be used to personalize my educational consultation experience.


Peptide Disclaimer. I acknowledge that many peptides discussed are research compounds, not FDA-approved for human therapeutic use except where specifically noted. Any use of research peptides is at the individual's own risk and discretion.


By signing below, I confirm I have read, understood, and agree to the above.

Client Signature
Date
Printed Name

WellSourced Certified Practitioner Program  ·  wellsourced.polsia.app

Confidential — Educational Use Only  ·  Page 1 of 1