Caregiving Systems Support Inquiry Form

Thank you for taking the time to complete this inquiry form. Your responses will help me understand your current caregiving situation, the support you are seeking, and whether this program is the right fit for your needs. The information you share will be treated with care and kept confidential.

First name

Last name

Phone

Relationship to the person receiving care

Brief description of the current caregiving situation

What feels most urgent or difficult right now?

What kind of support are you hoping to receive?

Are you ready to begin within the next 30 days?

Who else is involved in care or decision-making?

Are there any immediate medical, safety, legal, housing, or financial concerns?

Current stress levels (low / moderate / high)

Challenges or concerns you experience as a caregiver (emotional, physical, logistical)

How much caregiving responsibility currently falls on you?

What are the top 3 challenges you face right now?

What outcomes would make this support successful for you?

Availability / best times for sessions or visits:

Any special considerations (sensory, mobility, cognitive, emotional)

Is there anything important you’d like me to know before we meet? (Optional)

Disclaimer / Important Note: I am not a medical doctor, psychologist, or licensed mental health professional. My coaching and support are based on my personal experiences navigating caregiving, trauma, and family dynamics in my own life.

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