Form Fill Doula | It's A Nu Dai Community Lounge

Full Name*

Preferred Name (if different)

Pronouns

Email Address*

Phone Number*

Preferred Method of Contact (Email, Phone, Video Call, Other)*

Are you inquiring for yourself or a loved one?*

Myself

A loved one

Other

If other, please specify*

How did you hear about our end-of-life doula services?

What kind of support are you looking for? (Select all that apply)

Emotional and spiritual support

Home vigil planning & bedside presence

Facilitating Legacy projects & life review (letters, audio, video, memoirs)

Advance care planning & navigating end-of-life wishes

Grief and bereavement support (for self or family)

Post Death Home Organization

Elder Care

Other

If other, please specify

Do you or your loved one have a terminal diagnosis?

Yes

No, but facing aging or end-of-life concerns

Prefer not to say

If applicable, what is the current prognosis and stage of care?

Receiving medical treatment

Palliative care

Hospice care

Not currently receiving care

What are your biggest concerns or fears surrounding this transition?

Are there any specific religious, spiritual, or cultural beliefs you’d like honored?

Do you have an advance directive or end-of-life plan in place?

Yes

No, but would like guidance on creating one

Not sure

What would a peaceful and meaningful end-of-life experience look like for you or your loved one?

Are there any specific settings, sounds, or environments that bring comfort? (e.g., music, nature, candles, certain scents, etc.)

Are there important people, pets, or items you’d like present in this journey?

Would you like support with legacy projects or memory-making activities?

Would you like assistance in creating or planning a personalized ceremony, vigil, or celebration of life?

Who is part of your current support system? (e.g., family, friends, caregivers, clergy, therapists, etc.)

Would you like support in helping family members or loved ones cope with this process?

Do you need guidance in having conversations about death and dying with loved ones?

How can I best support you in this journey?

Is there anything else you’d like to share about your needs, wishes, or concerns?

What days/times are best for a consultation or first session?

Welcome!