Client Intake Form

*This is for serious applicants who are ready to begin their skin + wellness journey and commit to deeper support.


Hi! Thank you for taking the time to share more about your health, your trust means the world. I know how frustrating it can be to feel stuck in your symptoms, and I’m honored to support you on this journey. Whether you’re here for guidance, deeper answers, or long term healing, I’m here to help you feel seen, supported, and empowered every step of the way.

Let’s get started!

-Victoria ♡


Services
Clear Skin Consult $200: A 30 minute 1:1 session designed to give you personalized support and clear guidance on your skin concerns, nutrition, and lifestyle. This is perfect for you if you’re not ready for a full program but still need guidance on your skin and health journey.

Nourished Roots Program $1,500: A comprehensive 3 month 1:1 program designed to clear acne, balance hormones and restore gut health. Includes a full intake session, personalized nutrition and lifestyle protocols, progress check-ins, and ongoing guidance to help you build lasting, foundational health from the inside out. *This also includes a GI Map for every client.

Functional Lab Testing: Functional lab testing to uncover the root causes of symptoms like acne, gut issues, and hormone imbalances. Includes a personalized video walkthrough of your results, a custom protocol, and 7 days of email support to leave you feeling confident.

GI Map $670
DUTCH $650


If you're unsure which service is right for you please check out my website: https://www.victoriajewelwellness.com

For additional guidance please reach out via email: hello@victoriajewelwellness.com
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What service are you applying for? *
If you would like functional lab testing, which ones are you looking to run?
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First and Last Name *
Email *
Age *
Where are you located and what is your time zone? *
How did you hear about me? *
Please select all that resonate with you *
Required
What would you say are your biggest health struggles/concerns? Give me all the details! *
How long have you been dealing with these symptoms? *
How dissatisfied are you with your health? *
What are you currently doing to support your health goals? *
What are the biggest obstacles stopping you from accomplishing these goals? *
What would your life look like if it weren't for these health concerns? *
How often do you pass stool per day? If you aren’t going daily, how often do you go per week?
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What is your stool most often like using the Bristol Stool Chart?
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What does a typical "day in the life" look like for you? *
What does a typical day of your diet look like for you? Please be as detailed as possible including quality of ingredients and/or brands where applicable *
How many times a week or month do you eat outside of the home for any meals, snacks, desserts or beverages? What does this typically look like? What places / items? No judgement here! Please be as honest as possible
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How would you rate your overall quality of sleep?
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poor
amazing
On average, what time do you go to bed? *
How long does it typically take you to fall asleep once you're in bed? *
On average, what time do you wake in the mornings? *
How long does it typically take for you to get out of bed once you're up? *
How often do you experience difficulty falling asleep?
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Do you ever wake up during the night?
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How frequently do you experience daytime fatigue?
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Do you ever take naps? If yes, give me all the details! When, how often, how long, etc! *

Do you ever have difficulty concentrating or experience brain fog

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How would you explain the current state of your mental health and nervous system? *
How is your relationship with stress? What do you tend to do to combat it if those feelings arise?
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Anything I need to know regarding psychological history?
Are you willing to put in the necessary time and energy into supporting your health goals?
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Are you willing to make the necessary dietary and lifestyle shifts to support your health goals?
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Are you willing to take supplements? *
How committed are you to making changes in your health? *
Please list any conditions you've been diagnosed with and when you were diagnosed *
Please list any supplements and/or prescribed medications you take and how long you've been taking them (including topicals) *
Please list any known allergies to food, medications, skincare products etc.
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If you have skin concerns, what is your current skin care routine? What products are you using?
How much have you invested in your health so far including but not limited to copays, lab work, supplements, medication, practitioners and so on? *
Have we worked together before? *
How do you prefer to receive feedback and communication?
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What are you looking to take away and learn from your 1 on 1 support?
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Is there anything else you would like me to know about you before meeting?
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I understand and agree that my 1 on 1 support with Victoria Jewel Wellness is not medical advice and is for educational purposes only.
 *
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