Palliative Care and Bereavement Counseling Intake Form

Palliative Care and Bereavement Counseling Intake Form

Please complete this form to help us understand your needs. A counseling fee of $60 is required at the time of your visit.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact*
What are your Christian Counseling Needs?*
YesNo
If yes, please briefly describe your previous counseling experience.
YesNo
If yes, please list the medications.
How would you describe your current situation?*
Are you currently part of a church or faith community? If yes, please specify.
What are your goals or hopes for our work together?*
Have you or a loved one received a difficult diagnosis/prognosis?
Appointment
Signature
Date

MonthDayYear
Date
Should be Empty: