Death doula client intake form template
A free, stage-adaptive intake outline built on the PESP framework — physical, emotional, spiritual, practical.
Most intake forms borrowed from clinical settings ask a dying person forty questions in an order that serves the file, not the room. This template is organized the way an end-of-life doula visit actually moves: identify who you are talking to, establish where the client is in their journey, then work through the four PESP domains before you name goals, boundaries, and fees.
Use it as a paper worksheet, paste it into your own documents, or run it inside Liminal Desk, where the same structure expands and contracts based on the client's stage and stays searchable across your practice.
How to use this form without overwhelming a first visit
- Match depth to stage. For a planning-ahead client, sections 1, 2, 7, and 8 are usually enough. For an actively dying client, the physical and practical sections come first and the rest follows the family's pace.
- Fill it across visits. Intake is a relationship, not a form. Leave blanks visible so you know what is still unasked.
- Record language verbatim. The phrase a client uses for their own dying is clinical data. Do not translate it.
- Treat it as health information. Even if HIPAA does not name you, this document holds diagnosis, prognosis, and a home address. Store it somewhere access-controlled, not a shared drive.
The template
1. Client and contact details
The minimum you need to reach the right person quickly, and to know who is allowed to hear what.
- Client's preferred name and legal name
- Pronouns
- Date of birth
- Home address and directions / access notes (gate codes, parking, stairs)
- Best phone and email, and who else may answer that line
- Primary contact and relationship to client
- Secondary / emergency contact
- Who is authorized to receive updates about the client
2. Stage and current situation
Not every client is actively dying. The stage sets which sections you complete now and which can wait.
- Stage: planning ahead · living with serious illness · actively dying · vigil · after-death care · bereavement support
- Diagnosis or condition, in the client's own words
- Prognosis, if one has been given, and who gave it
- Current care setting (home, facility, hospital, hospice house)
- Hospice or palliative team involved, with contact
- What prompted the family to reach out now
3. Care team and household
Who is already in the room, so your work adds to it instead of duplicating it.
- Primary caregiver(s) and hours they cover
- Household members, including children and pets
- Physicians, nurses, social worker, chaplain
- Faith community, cultural or tribal community contacts
- Existing paid support (aides, night care, housekeeping)
- Known tensions or people the client does not want present
4. Physical (PESP)
Comfort is the ground everything else stands on. Record what is true today and what changes fast.
- Pain and symptom picture; what helps, what does not
- Mobility and transfer needs
- Sleep, appetite, hydration
- Medication routine and who manages it
- Sensory preferences: light, sound, touch, temperature, scent
- Equipment in the home (hospital bed, oxygen, commode)
5. Emotional (PESP)
What the client is carrying, and what they need from you emotionally.
- Client's understanding of their prognosis
- Fears named out loud, and fears hinted at
- Losses already grieved (role, mobility, home, independence)
- Mental health history relevant to support
- Family dynamics that affect the bedside
- What comfort looks like to this person
6. Spiritual and meaning (PESP)
Meaning-making is the work that outlives the visit. Use the client's own language.
- Faith, tradition, or worldview — and how actively practiced
- Rituals wanted before, at, and after death
- Beliefs about what happens after death
- Legacy work of interest (letters, recordings, ethical will, memory book)
- Unfinished business or relationships they want addressed
- Sources of meaning: music, nature, texts, animals, place
7. Practical (PESP)
The logistics that cause a crisis at 2 a.m. if they were never asked about.
- Advance directive / POLST — exists? where is it? who has copies?
- Health care representative or proxy, with contact
- DNR status and where the form is posted
- Will, trust, or estate contacts
- Funeral home, body-care wishes, home funeral interest, disposition plan
- Financial pressures affecting care decisions
- Insurance, veteran status, benefits in play
8. Goals, boundaries, and agreement
What the family is hiring you for, and what you are and are not offering.
- What the client hopes for from your support, in their words
- What the family hopes for (note where these differ)
- Scope of your services and explicit non-clinical boundaries
- Availability, on-call expectations, and vigil coverage
- Fees, package, sliding scale, deposit, invoicing rhythm
- Consent to document, consent to contact other providers
- Signature and date, client and doula
Run this intake inside your practice
Liminal Desk turns this outline into a working intake: sections open and close based on the client's stage, PESP notes carry forward between visits, advance directive details surface at the bedside, and everything stays isolated to your practice with encrypted, access-controlled storage. The free plan supports one active client, so you can run a real intake before deciding.