Client Intake FormPlease fill out this form so I can learn about you and prepare for our work together. Click to begin New Client Intake Form Client Name * First Name Last Name Client Email * Client Date of Birth MM DD YYYY Client Phone (###) ### #### I Identify my gender as Do you have an Advance Directive? Yes No Do you have POLST? Yes No Please share the name and phone number of your primary care physician If you have a hospice or palliative care program, chaplain, or any other members of your end of life team, please share their names and phone numbers here. What is your current diagnoses What is your current status? History of illness Medication(s) and purpose of each Cognitive impairment Pain level 1-10, describe pain, how it changes daily, location, and how it is managed Are there any other symptoms? Tell me about the family Family dynamics, issues, or events I should know about. Who will be present? Who should I reach out to after vigil? Please share names, relationship, and phone numbers Thank you!