Our Death Doula Client Intake Form is a comprehensive, professional document designed to help death doulas gather essential client and family information before end-of-life support begins. This intake form establishes a strong foundation for personalized care by organizing the details you need to understand each client’s emotional, spiritual, practical, and logistical needs. It is an essential tool for maintaining professionalism, improving communication, and supporting a compassionate, individualized end-of-life experience.
The key areas covered in the intake form include:
• Client Background Information
Basic personal information, household details, family structure, and support network to help you understand the client’s environment and relationships.
• End-of-Life Wishes and Goals
Documents personal values, care preferences, legacy desires, vigil preferences, and priorities for the end-of-life experience.
• Emotional and Spiritual Needs
Identifies emotional concerns, spiritual beliefs, comfort practices, and preferred forms of support to ensure aligned and meaningful care.
• Practical Support Preferences
Covers assistance with daily tasks, scheduling needs, communication preferences, and family guidance expectations.
• Medical and Health Information
Includes relevant medical background, mobility considerations, allergies, health limitations, and contact information for healthcare providers.
• Advance Directives and Legal Documentation
Provides space to record existing documents such as living wills, power of attorney, DNR orders, and other end-of-life planning materials.
• Emergency Contacts
Collects primary and secondary contact information to ensure communication is clear and accessible when needed.
• Cultural, Religious, and Personal Considerations
Allows clients to share cultural traditions, rituals, sensitivities, and personal practices important to their end-of-life journey.
Key Features
• Easy to Edit – Fully customizable form that can be personalized with your branding and practice details
• Comprehensive – Covers emotional, practical, medical, and spiritual aspects of end-of-life care
• Client-Centered – Helps create tailored, compassionate, and intentional support plans
• Digital or Print-Friendly – Use electronically for virtual sessions or print for in-person visits
How It Works
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Download the Death Doula Client Intake Form
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Open the file in Word, Google Docs, or a PDF editor and customize it to your services
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Use the form during consultations or send it electronically to gather organized client information
Please Note
• Personal Use Only – This form may not be shared, redistributed, or resold
• Digital Product – No physical item will be mailed
• All Sales Are Final – Due to the digital nature of this product, refunds are not available
This Death Doula Client Intake Form is a professional, customizable tool designed to support your death doula business, streamline client communication, and help you provide compassionate, well-informed, and individualized end-of-life care.
