Initial Care Client Intake
🌙 We are honored to walk alongside you. This form gathers details that help us provide care with clarity and respect. Please share only what feels comfortable.In our records, you’ll be listed as a Care Client, but in spirit, we walk together as Travelers.
About You
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Pronouns
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Current Support Circle
Primary Emergency Contact (Name, Relation, Phone)
Who else is part of your care or support circle?
Please include any names and any contact they are willing to share.
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Care Goals & Context
What brings you to us at this time?
Which areas of support feel most meaningful to you?
Advocacy at end of life
Advocacy during a medical journey
Comfort Care Planning at home
Comfort Care Planning at Hospice or Other
Vigil planning
Spiritual / ritual care
Legacy projects (storytelling, memory books, etc.)
Guided Memorial Planning (Prior to Need)
Death Cleaning or Downsizing
Grief Companioning
Pet Doula Services
Other (Please Share)
Current care team (hospice, physician, social worker, etc.)
Have you completed any of the following?
Advance Directive
POLST/MOLST or state-specific medical order
Funeral or burial plans
None of these yet
Personal Cultural & Spiritual Preferences
Are there spiritual, cultural, or community traditions you would like honored?
Preferred setting for care / vigil
Home
Hospital
Nursing Facility
Other (Please Share)
Family Dynamics (Optional)
Anything important for us to know about family roles, expectations, or relationships?
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