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Wisdom & Inspiration Newsletter from Sierra

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Elder Care, End-of-Life & Death Doula Support Inquiry

Thank you for reaching out to Choose Nurture. We are here to support you and your family with compassion, dignity, and specialized care during this profound transition. Please take a few moments to fill out this intake form so we can best understand your needs. All information shared is strictly confidential.

Section 1: Contact Information

Your Full Name *

Your Relationship to the Person Needing Care (The Individual) *

I am inquiring for myself

Child / Parent / Spouse / Sibling

Extended family member

Friend / Caregiver / Healthcare professional

Email Address *

Phone Number *

Preferred Method of Contact

Phone call

Text message

Best Time to Contact You

Section 2: About the Individual Needing Care

Individual's Name (or Preferred Name)

Current Location / City & State *

Where is the individual currently residing?

Private Home

Hospital

Hospice Facility

Assisted Living / Nursing Home

Current Health Status / Diagnosis (If comfortable sharing)

Is the individual currently enrolled in or receiving Medicare/Private Hospice care?

Yes

In the process of setting it up

Unsure

Section 3: Timeline & Urgency

What is the current timeline or urgency for services? *

Immediate Need: Transitions are actively occurring / Imminent death.

Imminent Need: Weeks to a few months.

Early Planning: Months ahead / Recent diagnosis.

Pre-Planning: Healthy, but looking to organize end-of-life wishes in advance.

Section 4: Desired Support & Services

Which areas of support are you most interested in exploring? (Select all that apply)

Emotional & Spiritual Support: Companionship, active listening, and a calming presence.

Logistical & Practical Guidance: Organizing paperwork, advanced directives, and planning final wishes.

Vigil Support: Being present at the bedside during the active dying process.

Legacy & Life Review Projects: Helping create memory books, letters, or audio recordings.

Respite Care for Family: Providing a break for primary family caregivers.

Grief & Bereavement Support: Comfort and guidance for loved ones.

Funeral / Memorial Planning: Assisting with alternative or personalized celebration-of-life planning.

Unsure: I would like guidance on what might be most helpful.

Are there any specific spiritual, cultural, religious, or personal traditions that are important to honor?

Section 5: Additional Context

Please share any other details, worries, or specific goals you have for this chapter. How can we best nurture your family right now?

How did you hear about Choose Nurture?

Submit Inquiry & We will Respond ASAP

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Wisdom & Inspiration Newsletter from Sierra

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Elder Care, End-of-Life & Death Doula Support Inquiry

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