Caregiver intake Form

I’d love to learn more about you and how I can support you while you care for your loved one in their final phase of life. Please feel free to fill out the form and note any context for yourself and any other members of the care team.

Caregiver intake form

Caregiver name

First Name

Last Name

Caregiver email

Caregiver phone

(###)

###

####

General health status

Do you have any health issues of which I should be aware?

Level of exhaustion

(1-10)

How are you handling your exhaustion?

Sleep pattern:

How well are you eating?

Tell me how you feel you're managing your role as caregiver

Tell me what might help you

Tell me how you're managing your life outside of caregiving

What changes would you like to make in regards to this?

Tell me about your support system

Is there a friend I should know that I can contact on your behalf for support?

Do you have a religious affiliation?

Catholic

Protestant

Mormon (Latter-Day Saints)

non-Denomination

Muslim

Not practicing any religion

Other

Prefer not to say

What is important for me to understand about your culture and/or ethnic background?

What concerns you as you think of the time ahead?

Is there anything else you can think of that I should know?