Steady Hearts — Care Assessment Intake Form

Steady Hearts — Care Assessment Intake Form
This assessment helps determine the appropriate level of support, scope of services, and pricing prior to your intake call. Completing this form does not commit you to services.
Name
Client Context
Who is this support for?
Primary diagnosis (if known):
Current treatment phase:
Primary care facility or oncology team:
Care Complexity
How many providers are currently involved? (1 / 2 / 3+)
Are there upcoming treatments or procedures? (None / Minor / Major)
How often is coordination currently needed? (Monthly / Weekly / Multiple times per week)
Responsibility & Support Burden
Who currently manages care coordination?
How confident are you tracking appointments and results?
Are you feeling overwhelmed by managing care right now?
Urgency
Do you need support urgently (within 7 days)?
Are there unresolved or time-sensitive issues?
Support Needs

Select all that apply
Understanding diagnosis or treatment optionsAppointment preparationScheduling or coordination supportInsurance or administrative assistanceMedical record organizationCare roadmap or planningCaregiver supportFollow-up trackingClinical trial researchUnsure / need guidance
Billing Preference
Preferred billing style: Hourly / Package / Unsure
Financial Access (Optional)
Which best describes your current financial situation related to care?
(Significant strain / Some strain / Stable / Prefer not to answer)
Additional Information
Anything else you would like us to know:
Should be Empty: