Caregiver Relief & Senior Support Intake

Caregiver Relief & Senior Support Intake
SECTION 1 — Who Is This Form About?
Thank you for being here. Caring for an aging adult can be exhausting and confusing, especially when the medical system is slow, fragmented, or unhelpful. This form is meant to make your next steps easier. You do not need to prepare anything in advance. Just share whatever you can. A few sentences or even a short note are enough for us to begin helping.

You may fill this out as a caregiver, as the patient, or together. Everything you share is private and reviewed directly by our clinical team. After you submit the form, we will look over the information and reach out with a clear and supportive plan.

All information you share here is confidential and protected. CED Clinic handles every submission under HIPAA-compliant privacy standards.
Your Name

First NameLast Name
Your Relationship to the Person Needing Care
Name of the Person Who Needs Care
Age of the Person Needing Care
State of Residence (for telehealth rules)
Hint: Please enter the state where the patient currently lives.
Is the person aware that you are reaching out today?
SECTION 2 — Your Primary Concern
What prompted you to seek help today?
Briefly tell us what is going on, what worries you most, or what feels overwhelming right now
Which issues are you hoping we can help with?

PainSleep problemsAnxiety or nervousnessOverwhelm or emotional distressMemory changes or cognitive declineMedication problemsToo many medications or supplementsNot eating wellLow energy or low activityTrouble with mobilityPreparing for a procedure or diagnosisCannabis guidancePrimary care style supportTalk-based visitsSupport for the caregiverOther
SECTION 3 — Medical Background (Simplified)
Current Diagnoses (if known)
List anything previously diagnosed, even if you’re unsure
Current Medications and Supplements
If you’re not sure of the full list, write what you remember
Recent Medical Events or Hospitalizations
Optional but recommended
Are there medications or treatments that have caused problems?

YesNo
If Yes, which ones, and what happened?
Upload any helpful documents (optional)

If you have a medication list, recent visit summary, or discharge paperwork, you may attach it here.
Cancelof
SECTION 4 — Cannabis-Specific Questions
Has the person used cannabis before?
What are your goals for cannabis care?

Reduce painImprove sleepReduce anxiety or agitationSupport moodReduce medication burdenIncrease appetiteSupport daily functionI’m not sure yetOther
Any prior negative reactions to cannabis?

YesNo
If Yes, Please Describe
SECTION 5 — Logistics and Communication
Who should we communicate with first?
How urgently do you need help?
Best way to reach you

PhoneText MessageEmailAny of The Above
Preferred Language for Communication
What Language?
Best time of day to reach you
If you have a specific day or date that works best, let us know here.

MonthDayYear
Date
Your phone number
Your email address
example@example.com
SECTION 6 — Care Preferences
What type of support are you looking for?

One-time consultationOngoing care and monitoringCaregiver supportTalk-style visitsPrimary care guidanceCannabis care planSecond opinionHelp coordinating other doctorsNot sure yet
Would you like us to take over as much as possible?
SECTION 7 — Consent and Next Steps
We use this information only to understand what you need and how to help. Your details remain private and secure
How did you hear about us?
I agree to be contacted by the CED Clinic team.

I consent to be contacted by CED Clinic about this request.No thanks
Signature

Powered by Jotform SignClear
Anything else you want us to know before we reach out?”
Optional, but helpful
Should be Empty:

Caregiver Relief & Senior Support Intake

SECTION 1 — Who Is This Form About?

SECTION 2 — Your Primary Concern

SECTION 3 — Medical Background (Simplified)

SECTION 4 — Cannabis-Specific Questions

SECTION 5 — Logistics and Communication

SECTION 6 — Care Preferences

SECTION 7 — Consent and Next Steps