Client InformationClient’s Full Name: First (Client) Address: Street Address Date of Birth:PhoneEmail Address Street Address Emergency Contact Name: First Health Care Power of Attorney: First Emergency Contact Phone Number:Health Care POA Phone Number:Referring Party (If Applicable)Name of Referring Party: First Relationship to Client: First Email Phone1. End-of-Life Care Preferences A. What is the client’s diagnosis or prognosis (if applicable)? Yes No If yes, please provide details:B. Is the client currently receiving any medical treatment or hospice care? Yes No If yes, please provide details:C. Does the client have a specific diagnosis, condition, or terminal illness? Yes No If yes, please provide details:D. Are there any specific medical interventions or treatments the client wishes to avoid or pursue at this stage? Yes No If yes, please provide details:2. Emotional & Psychological Considerations A. Has the client received any psychological counseling or therapy? Yes No If yes, please provide details:B. How does the client feel about death and dying? Accepting Anxious Fearful In denial Other: please provide details:C. Does the client have any specific emotional or spiritual needs or requests regarding their end-of-life experience? Yes No 3. Spiritual & Cultural Preferences A. Does the client adhere to any particular religious or spiritual beliefs? Yes No If yes, please provide details:B. Are there specific rituals, practices, or prayers the client would like included in their end-of-life care? Yes No C. Is the client open to receiving spiritual support, regardless of their religious beliefs? Yes No 4. Physical & Comfort PreferencesA. What types of comfort measures does the client prefer? (e.g., physical touch, soothing music, relaxation techniques) Yes No B. Are there any specific pain management preferences or concerns the client has? Yes No C. Is the client currently receiving any medication for pain or other symptoms? Yes No If yes, please provide details:5. Family & Social SupportA. Does the client have family or caregivers involved in their care? Yes No If yes, please provide details:B. Is there a designated family member or other support person who will act as the main point of contact? Yes No Name First PhoneAddress Street Address 6. Practical Arrangements A. Does the client have any pre-arranged funeral or memorial plans? Yes No If yes, please provide details:B. Would the client like assistance with advance directives, such as living wills, Do Not Resuscitate (DNR) or POLST orders? Yes No C. Are there any legal documents that Final Chapter should be aware of (e.g., Power of Attorney, healthcare proxy)? Yes No If yes, please provide details:7. End of Life WishesA. Does the client have any preferences regarding the location of their care at the end of life (e.g., home, hospice, hospital)? Yes No If yes, please provide details:B. Does the client wish to receive any specific types of visits, such as from clergy, family, friends, or other support individuals? Yes No If yes, please provide details:C. Does the client have any preferences regarding food, drink, or other personal care items? Yes No 8. Consent & Acknowledgement a. Consent to End of Life Doula Services: By signing below, I acknowledge that I have provided accurate and truthful information in this Intake Form to the best of my knowledge. I consent to receiving end of life doula services, understanding that these services are non-medical and will complement medical care as appropriate. I further understand that these services are not reimbursable by Medicare, Medicaid, health care insurers, or long term care insurers. Client’s Signature:Client’s Signature:Date:Date MM slash DD slash YYYY Doula’s Signature:Doula’s Signature:Doula’s Signature:Date:Date MM slash DD slash YYYY CAPTCHA
