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 or A Family Member
Please take the time you need to share what you are able as a family or chosen family circle. The primary fields listed below are regarding the care of the primary client. However, we also serve families as a whole. Please continue to introduce us to the whole circle, and any contact preferences in the next fields
Care Client - Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
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
Preferred Method of Contact Phone/Text/Email?
Please indicate any needs or preferences your caregiver may also have, if different from yours
Best/Most Comfortable Time of Day to Contact?
Emergency Contact Information
Primary Caregiver's Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Care Client
Preferred Pronouns
Preferred Method of Contact Phone/Text/Email?
Please indicate any needs or preferences your caregiver may also have, if different from yours
Best/Most Comfortable Time of Day to Contact?
Address if Different from Care Client
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is the primary recipient of support at this time?”
The Care Client
The Primary Caregiver(s)/Family
What brings you to us at this time?
Which areas of support feel most meaningful to you today?
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)
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Current Support Circle
Other Emergency Contact(s) (Name, Relation, Phone)
Who else belongs in your closest circle of care?
This may include family members, close friends, chosen family, caregivers, or others who are directly involved in your care or support.
Who belongs in your wider circle of care?
This may include clergy or spiritual leaders, close friends, neighbors, chosen family, advocates, or anyone else who offers meaningful non-medical support.
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Hospice Status & Framing
Are you currently enrolled in Hospice care?
Yes
No
If yes, can you answer a few more questions about your hospice care status?
If not currently enrolled, are you open to considering hospice care in the future?
Yes
No
Unsure
If not open to hospice care, please share your reasons or concerns:
Of course this is optional but we may able to connect you with resources which can help address these concerns safely and empower you to manage your further care.
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Healthcare Goals, Status, & Context
This section helps us understand your current health status, physical condition, and care goals so we can better support you. Your responses are confidential and will remain between you and your doula unless you give us direct consent to share them with others.
Current Diagnosis, Health Condition, or Physical Concerns
Please share as much or as little as you feel comfortable sharing about any diagnoses, health conditions, or physical changes you are navigating. We ask so we can better understand your needs and support you as a whole person.
Current Medications or Supplements
Rows
Medication or Supplment
Dosage
Frequency
Purpose
1
2
3
4
5
6
7
8
9
10
Recurring Treatments, Therapies, or Care Modalities
Rows
Treatment / Modality
Provider / Care Team
Schedule / Frequency
Purpose / Support Goal
1
2
3
4
5
Mobility, Accessibility & Medical Equipment
Please share any mobility aids, assistive devices, accessibility needs, or medical equipment currently in use or expected soon. This may include a cane, walker, wheelchair, hearing aids, CPAP/BiPAP, oxygen equipment, hospital bed, lift chair, commode, shower chair, wound care supplies, or medication management tools. This helps us better understand what support, setup, or local resources may be helpful.
Anything else you would like us to know about your care, support needs, or upcoming health-related decisions?
You are welcome to share anything that did not fit above, including concerns, changes you are anticipating, resources you may need help finding, or anything you feel would help us better understand your situation.
Current or Upcoming Health Care Team
Please share any current or upcoming members of your care team, including hospice, palliative care, specialists, primary care, social workers, therapists, home health, complementary/integrative care, and other healthcare support providers. While we do not provide medical care or social work services, this helps us understand what support is already in place and what resources may still be needed or desired.
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Planning Status & Next Steps
This section helps us understand what planning you have already completed, what may still need attention, and where you may want support in the future. It is completely okay if you have not completed these steps yet — many people begin this work one conversation at a time.
Have you completed any of the following?
Advance Directive
Living Will
Designated Health Care Representative / Medical Power of Attorney
POST/POLST/MOLST (Physician Orders for Life Sustaining Treatment) or state-specific medical order
Do Not Resuscitate (DNR) Orders (Care Facility Specific)
Funeral, burial, cremation, or memorial plans
Funeral Planning Declaration
I have started thinking about these, but nothing is finalized yet
None of these yet
I am not sure
Anything you would like us to know about your planning documents or next steps?
Optional: You are welcome to share any helpful details here, such as who your decision-maker is, where documents are kept, whether your loved ones know your wishes, or what you may want support reviewing, clarifying, or completing.
Where would you prefer to receive most of your care and support, if possible?
Home
Hospital
Nursing Facility
Assisted Living
Hospice Facility
Not Sure
Other (Please Share)
Preferred place of death
Home
Hospital
Nursing Facility
Assisted Living
Hospice Facility
Not Sure
I am not prepared to answer at this time
Other (Please Share)
Preferences, Hopes, or Concerns About Place of Care or Death
Optional: You are welcome to share anything that feels important about where you hope to receive care, where you would prefer to die if circumstances allow, or any concerns, fears, or practical needs connected to those wishes.
Personal Cultural & Spiritual Preferences
Optional: Please share any spiritual, cultural, religious, family, or community traditions you would like us to be aware of or help honor during serious illness, vigil, death, or after-death care. This may include simple practices, such as opening a window, playing certain music, lighting a candle, prayer, silence, storytelling, washing or tending the body, or allowing space for specific expressions of grief. You may also detail complex practices and religious resources. Our job is not to promote nor detract from ANY cultural or religious point of view or spiritual health. We are here to facilitate or arrange for your spiritual support to be present in accordance with your identity or wishes. We welcome whatever feels meaningful, ordinary, sacred, or important to you.
Family Dynamics (Optional)
Optional: Families and support circles can be loving, complicated, or both. You are welcome to share anything that may help us understand roles, relationships, expectations, concerns, communication needs, or areas where extra care may be needed. This information will remain between you and your doula unless you give direct consent to share it.
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In Case You Have Already Thought of These Steps...
Wherever you are in your journey, we want to help facilitate the next steps. Some people are ready to provide answers on this page--and some people are not. We invite you to consider these answers and provide what you may already know about yourself in the spaces below. Don't worry--if you do not have the answers yet. We will help guide you toward communicating these wishes if you are ready or are in a position where contemplating the answer may be more urgent.
Death Nesting Preferences
Coined by death educator and end-of-life doula Anne-Marie Keppel in her book Death Nesting: The Heart-Centered Practices of a Death Doula, Death Nesting is the conscious practice of preparing a supportive, comforting, and sacred environment for a dying person, directly mirroring the concept of "nesting" before childbirth. It focuses on shifting end-of-life care away from a purely sterile, medical experience toward a holistic process that honors a person's physical, emotional, and spiritual needs.
Favorite Flavors/Cuisine
Hunger and thirst are often the first senses to diminish when a person is preparing for death. However, sometimes people may be "mouth hungry" or "taste hungry" some months before death. Let us know what you like and do not like here so we can help you find resources for comfort.
Atomosphere Prefeence
Do you know your current Myers-Briggs personality? Are you extroverted or introverted? Do you think you would like lots of people around you at one time, or a few? Perhaps one? Do you like the idea of quiet? Is there a pet you would like to allow in your room? Do you wish to picture yourself in a bedroom or in a living room? Perhaps you know what you do not wish to have in the room with you or the atmosphere--feel free to outline that preference as well here.
Scents or Aromatherapy Preferences?
Lighting Preferences
Music Preference or Sounds
Describe your most comforting music or playlist. Is there anything specific you use to fall asleep like calm
Any other sensory preferences
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Emotional & Psychological Support
This optional section helps us understand some insight you may or m any not already have about yourself and the actively dying phase what may still need attention, and where you may want support in the future.
Current Coping Mechanisms
Strategies that work well for you
Past Experiences with Death and Dying
Significant losses and their impact
Most Current Emotional and/or Spiritual Concerns
Current Fears and Anxieties
Unresolved Issues or Conflicts
Support Groups or Counselors (if applicable)
Counrselor or Therapist's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Support Group (s) if applicable
Cultural or Ethnological Considerations
Please list any cultural or ethnic environmental preferences you may wish to convey to home care helpers or to include in your end-of-life care plan
Pets and their care and provisions
What pets are your primary family members? Include any pets, a bit your relationship and what we should consider when thinking about their care today and tomorrow.
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Legacy and Memory Making
This optional section is provided for those care clients who have started thinking about their memorial planning or who have finished this planning, or who have not started to plan, but would like to begin today. Do not begin to fill this in if you are running out of energy or if you aren’t ready. These are things we will absolutely talk about together if you would prefer.
Type a question
Legacy Projects
If you have started or would like to start writing your own obituary, creating a life story in any written or visual form, please let us know the particulars in this section.
Important Letters
Videos
Scrapbooks
Other
Desired Memory Making Activities
Special Legacy Requests for Family and Friends
Final Messages or Wishes
Most Important Messages for Loved Ones
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After Care for You or Your Loved Ones
Similarly, this final section relative to Post-Death Care is optional for care clients who have started this planning or wish to begin and have some thoughts. We will absolutely help with this section at a future time if you do not know where to begin.
Funeral or Memorial Service Preferences
Type of Service or Services -- (Religious, Secular, Themed, etc.)
Specific Requests for Any Services
Officiant, readings, etc.
Preferred Funeral Home or Memorial Care Center
Preferred Funeral Director Name (If Applicable)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Disposition Preferences (e.g., burial, cremation)
Common Contemporary Methods
Burial (in Ground)
Above Ground (Mausoleum or Crypt Space)
Cremation
Location
Plot, Crypt, Niche or Deed Number. In the case of cremation, where would you like your Ashes to be located or distributed
Alternative Disposition Options (select any you have chosen or would choose if available)
Green Burial
Conservation Burial
Aquamation, Alkaline Hydrolysis, Water Cremation
Body Donation to Science
NOR (Natural Organic Reduction)
Other
Are you available as an organ donor?
If so please specify any particular organs you would rather NOT Donate
Other special requests for the handling of personal belongings
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