Client Intake Form

Hello, and thank you for trusting me to support you at this time. To ensure that your needs are met and provide clear understanding of services at the time of our consultation, please consider and answer the following questions.

Your information will be kept private, and will not be shared or discussed without your consent. If you prefer not to complete personal information questions, leave them blank and I will complete them if we decide to work with one another!

I look forward to speaking with you,

Kate

Name

(client name)

First Name

Last Name

Pronouns

Phone

(###)

###

####

Address

Address of primary client/where visits would be made. (Visits outside of the Los Angeles area can be done virtually)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for Consultation

What has prompted looking into working with a Death Doula?

Support System/Caregiver

Who are the people in your life supporting or assisting your in your care, or are you providing care to someone else (please include their names and relationship to you)

Other relevant information

Anything else I should know?

Section

Areas of support

Please mark any items you would like support with or have interest in learning more about.

Guidance with Advance Medical Directive

Guidance with Health Care Proxy completion

Guidance with completion of non-medical directives (pre planning tool)

Hospice information

End of Life care education

Creative legacy projects (Life review)

Companionship and/or Emotional Support

Herbalism