Client Intake Form

Welcome - Let's Start Here

This short intake helps me understand where you are right now, so I can support you in the most thoughtful and personalized way possible. Please answer honestly and take your time — there are no right or wrong answers.

Client Baseline Form

Full Name

Email (the same one you used to sign up for the program)

Age

Gender

Country

All information shared in this form is confidential and will be used solely to support you during The Lupus Remission Project. Your information will never be shared.

What is your diagnosis (or diagnoses), and when were you first diagnosed?

Please describe your symptoms and how they affect your daily life. (Examples: fatigue, joint pain, rashes, brain fog, digestive issues, headaches, sleep problems, mood changes — please describe in your own words.)

What treatments, approaches, or therapies have you tried so far, and how did they go? (Examples: medications, supplements, dietary changes, lifestyle changes, alternative therapies — what worked, what didn’t?)

Please describe your current eating habits. In the past 2 days, what did you eat for breakfast, lunch, dinner, and snacks? What did you drink?

What do you do for pain relief?

Do you smoke cigarettes?

Do you drink alcohol?

Do you have any questions for Sandia right now? List them here!

This is Sandia writing--I read every form personally, so I can better understand your situation. I look forward to learning more about you and your journey so far. :)

These questions in this form help me better understand and support you and are not used for medical diagnosis. Check the box to acknowledge your understanding.

Welcome - Let's Start Here

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