Thanadoula Client Intake Form

Thanadoula Services Client Intake Form
Name

First NameLast Name
Birth Date

MonthDayYear
Preferred Pronouns

She/HerHe/HimThey/ThemOther
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What services are interested in?

AdvocacyCompanionshipStress ReliefUnderstanding DeathAdvanced Care DirectivesOn Call ServicesLegacy ProjectReiki TherapyFuneral ArrangementsMeditationVigil FacilitationPhone CallsAfter Death Support for FamilyLight HousekeepingCremains JewelryShort ErrandsPet ServicesOther
Is there any injuries, surgeries, or recent health conditions that you feel the need to share?
Disclaimer: the Gypsy Lotus Collective is not a western medical health center and does not claim to diagnose or cure medical conditions. Utilizing essential oils should not take place of medical care.
Please sign below if you acknowledge the given information and give your consent to receive care.

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Thanadoula Services Client Intake Form