Fool’s Reflection

Begin Your Reflection

This intake form helps us understand your goals, preferences, and practical needs before we begin any personalized tea consultation. It gives our team the context needed to respond with care, clarity, and a grounded recommendation path.

Fool’s Reflection consultations are designed to be deliberate and tailored. Share as much relevant detail as you can, and we’ll review your submission to determine whether your request aligns with our current scope, process, and capacity.

Please note: completing the intake form does not guarantee that a formulation request will be accepted.

Complete the Intake Below

Pre-Consultation Intake

Tell us how your routine works today so we can shape a thoughtful blend recommendation.

This intake helps Fool’s Reflection understand your goals, flavor preferences, schedule, and practical needs before consultation.

1. Contact Information

Share the best way and time to reach you.

Full name

Phone

Preferred contact method

Best days and times for a consultation

Preferred format

3. Daily Routine

A clear snapshot of your schedule helps tailor timing and strength.

Typical wake time

Typical bedtime

Work or daily schedule

Intended time of tea use

Desired servings per day

Usually prepared at home, work, or while traveling

5. Caffeine

Understanding your current intake helps avoid over-stimulation.

Current caffeine sources

Approximate daily intake

How caffeine usually affects the client

Desired blend

Caffeinated Low-caffeine Caffeine-free Unsure

Latest comfortable caffeine time

6. Allergies and Restrictions

Please provide complete and accurate information. Ingredient safety depends on knowing about allergies, sensitivities, and restrictions before a blend is considered.

Known food herb spice pollen or supplement allergies

Previous reactions to tea herbs or supplements

Ingredients that must be avoided

Dietary religious ethical or personal restrictions

7. Preparation and Practical Needs

Practical details help us design something you can sustain day to day.

Access to a kettle

Access to an infuser

Access to refrigeration

Preferred preparation time

Desired quantity

Approximate monthly budget

Simple daily blend or more involved tea ritual

8. Previous Experience

Previous outcomes help us avoid repeating what didn’t serve you.

Has the client used functional teas or herbal products before

What worked well

What did not work well

Has the client stopped using a blend because of taste cost inconvenience or an unwanted effect

9. Medications and Supplements

Share current and occasional products so ingredient compatibility can be screened responsibly.

This information is requested only to identify possible ingredient concerns. Fool's Reflection does not provide medical advice or interpret medications as a healthcare provider.

Current prescription medications

Over-the-counter medications

Vitamins supplements tinctures powders gummies or herbal products

Medications used only occasionally

Ingredients a doctor or pharmacist has advised the client to avoid

11. Required Acknowledgments

Please confirm each statement before submitting your intake.

Please do not submit medical records, insurance information, Social Security numbers, payment-card information, or unrelated sensitive information. Information submitted through this form will be used only for consultation review, ingredient-safety evaluation, communication, and formulation planning.

I understand that Fool's Reflection creates personalized food and beverage products and does not diagnose, treat, cure, or prevent medical conditions. I understand that submitting this form does not guarantee that Fool's Reflection will accept or formulate my request. I certify that the allergy, medication, supplement, pregnancy, and ingredient-safety information I provided is accurate to the best of my knowledge. I understand that I may be asked to consult a doctor or pharmacist before certain ingredients are used. I consent to Fool's Reflection using this information to evaluate my request, communicate with me, and develop a personalized tea formulation if my request is accepted.

Thank you. Your Reflection intake has been received. I will review your information before determining whether a consultation can be scheduled. Please watch your email for the next step.

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