INTAKE FORM

INTAKE FORM
BEFORE YOU BEGIN
This intake form is designed to help determine the appropriate level of patient advocacy support. Patient advocacy focuses on organization, communication, and navigation within the healthcare system.

This service does not provide medical advice and is not intended for emergencies.
Please acknowledge below*

I understand this service is not meant to replace medical adviceI understand this service is not for emergencies

WHO IS THIS FOR
I am the:

PatientFamily member/caregiverOther
Best contact name
Best contact email
Best contact phone (optional, but helpful)
Preferred Contact

PhoneEmailBoth

PATIENT OVERVIEW
Patient age range:

Under 1818-4041-6465+
Current care setting

HospitalRehab/Skilled NursingAssisted LivingAt homeOutpatient only

WHY IS SUPPORT NEEDED
What prompted you to seek advocacy support? (check all that apply)

Recent hospitalization or dischargeMultiple doctors/specialistsConfusion after appointmentsDifficulty organizing care or informationFeeling overwhelmed or unsure what to askInsurance or care coordination concernsOther

APPOINTMENT AND CARE CONTEXT
Are there upcoming appointments?

YesNoNot sure
If yes, when is the next appointment?

Within 7 days1-4 weeksMore than a month away
Is the patient managing care alone?

YesNoSometimes

TYPE OF SUPPORT REQUESTED
What type of support are you seeking? (select all that apply)

Appointment supportHelp understanding next stepsCare coodination supportOngoing advocacy guidanceNot sure - I need help figuring that outOther

CONSENT
Checkbox acknowledgment

I consent to being contacted regarding advocacy support
Should be Empty: