Consultation Intake | Katelin Hubbard, PhD Consulting

Contact Information

Full name *

Email address *

Phone number

City / Country

Age

Preferred pronouns (optional)

How You Found Me

How did you hear about this practice?

Word of mouth / referral Instagram or social media Google search Facebook group or online community Referred by a doctor or healthcare provider Other

If referred or "other" — any additional detail? (optional)

What Brings You Here

What is the primary reason you're seeking a consultation? * Be as specific as you'd like. What's going on, and why now?

What are your main goals for this consultation?

Understand my genetics / DNA data Find the root cause of symptoms that haven't been explained Get a personalized supplement and nutrition plan Optimize general health and longevity Support a chronic illness or complex diagnosis Understand how my genes affect my medications Get something concrete to bring to my doctor Athletic performance or recovery optimization Other

Anything else you'd like me to know about your goals?

Health History

Current diagnoses or conditions List anything you've been formally diagnosed with, or that you strongly suspect but haven't been diagnosed.

Current symptoms List your most significant symptoms, especially ones that are unexplained or haven't improved with treatment.

Significant health history Surgeries, hospitalizations, major illnesses, childhood conditions, reproductive history, trauma history — anything you feel is relevant.

Family health history Any notable conditions in parents, siblings, or grandparents — especially heart disease, cancer, autoimmune, neurological, or metabolic conditions.

Medications & Supplements

Current medications Include prescription medications, over-the-counter medications, and anything taken regularly.

Current supplements List vitamins, minerals, herbs, or other supplements you're currently taking.

Known medication or supplement reactions Have you ever reacted badly to a medication, supplement, or anesthesia? If so, describe what happened.

Genetic Data

Do you have raw DNA data available? * This includes an exported raw data file from 23andMe, AncestryDNA, MyHeritage, or whole genome sequencing (WGS) from services like Sequencing.com.

Yes — 23andMe Yes — AncestryDNA Yes — MyHeritage Yes — Whole Genome Sequencing (WGS) like Sequencing.com Yes — other DNA testing service No — but I'm interested in getting tested No — I want to work from symptoms and labs only Not sure

Great — the genetics screener is included below. After you finish this intake section, Part 2 will walk you through 20 genetic pathways so I can identify which reports are most relevant before your consultation. It takes an additional 10–15 minutes.

No problem — no genetic data is required. I'll skip the genetics screener for you. Continue through the rest of this form and submit when ready.

Do you have recent lab work available? Mention any relevant panels — CBC, metabolic panel, thyroid, homocysteine, organic acids, hormones, etc. Alternatively, you can upload your lab results to a Google Drive or Proton Drive folder and share

Budget & Package Preference

Do you have a package in mind?

Genetics Foundations ($400+) Symptoms Foundations ($400+) Genetics + Symptoms Deep-Dive ($400+) Full Transformation ($1,200+) Single service or add-on I need sliding scale pricing — please reach out about options Not sure — please recommend

Anything else you'd like me to know before your consultation?

Consultation Intake Form

Ready to submit?

Thank you, friend.