Form

Form
Next Steps Outreach, LLC

Client Intake & Onboarding Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What state are you physically located in during sessions? *
Example: Illinois
General information

Please answer the following questions to help guide your sessions
What would you like to focus on during support sessions?
Optional Information

This information is voluntary and used only to better understand support needs. This service does not provide medical care, diagnosis, or treatment.
Do you have any health conditions you would like to share that may impact your support needs?

NoneDiabetesHigh Blood PressureHeart Conditions (including congestive heart failure)OtherPrefer not to say
Support Preferences

Please help us understand how to best support you.
What type of support are you primarily seeking?*

Emotional supportResource navigation (housing, benefits, services)Goal setting/accountabilityPeer conversation/check-insNot sure yet
Communication Preference

Choose the option that works best for you
How would you prefer to receive support?*

Phone callVideo callText/messagingIn-person (if available)
Availability
What time of day are you most available?*

MorningAfternoonEveningFlexible
Frequency
How often would you like support sessions?*

WeeklyBi-weeklyMonthyAs needed
Barriers
Are there any challenges or barriers that may affect your ability to participate in sessions?
Example: things like transportation challenges, scheduling conflicts, childcare needs, work hours, access to phone/internet, or health-related limitations
Support Goals
What would you like to gain from peer support?*
Example: emotional support, accountability, connection, guidance, consistency
Experience Level
have you participated in peer support or similar services before?

YesNoNot sure
Urgency/Priority
How soon are you looking to begin support?*

As soon as possibleWithin the next 1-2 weeksWithin the next monthJust exploring options
Safety/Boundaries
Is there anything you would like us to be aware of to help support you safely?
Service Commitment & Payment Understanding
Consent & Service Agreement

Please read and confirm your understanding of the following:

• I understand that Next Steps Outreach provides peer support services and does not replace medical, clinical, or licensed therapy care.

• I understand that services are paid in full prior to scheduling or receiving sessions.

• I understand that I must select either:
- a single session, OR
- a minimum package of four (4) sessions

• I understand that no services will be provided without completed payment.

• I understand that payments are processed electronically through approved platforms.

• I understand that missed sessions or late cancellations may result in forfeited session time.

Please enter your initials to confirm your understanding and agreement
*

Yes, I understand
Signature*
Consent/Understanding
I understand that this service provides peer support and does not replace medical or clinical care. Please enter your initials to confirm your understanding.*

Next Steps Outreach*

Consultation Call

No payment required, just selection

$ Free Quantity

Single Session

60 minutes

$100.00 Quantity

4-Session Package

4- separate 60 minute sessions

$360.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By signing below, I confirm that I understand the service terms, payment policy, and agree to proceed with services.
Final Agreement & Authorization

Form

Next Steps Outreach, LLC

General information

Optional Information

Support Preferences

Communication Preference

Availability

Frequency

Barriers

Support Goals

Experience Level

Urgency/Priority

Safety/Boundaries

Service Commitment & Payment Understanding

Consent/Understanding