Sacred Passage Support

Intake & Support Request Form

All information shared is confidential and used only to help us support you thoughtfully and respectfully.

Full Name *

Email *

Phone

Who Is This Support For?

Who are you reaching out about? *

Myself

A loved one

A patient or client (with permission)

Your relationship to the individual needing support *

Self

Spouse / Partner

Parent

Child

Other family member

Caregiver

Other

Current Care Situation

Which best describes the current situation? *

Receiving hospice care

Facing serious illness (e.g., cancer, chronic or life-limiting condition)

Not on hospice but needing additional support

Caregiver seeking support

Unsure / still navigating options

(check all that apply)

If applicable, has hospice already been involved? *

Yes

Not Sure

Not Applicable

What Kind of Support Are You Seeking?

What type of support are you most interested in? *

Emotional support and compassionate listening

Education on non-invasive, complementary wellness approaches (non-medical)

Support with comfort-related concerns (digestive discomfort, nausea, restlessness, emotional distress)

Guidance for caregiving and family support

Support during end-of-life transitions

Not sure — I’d like to talk it through

(check all that apply)

What Are You Hoping For Right Now?

In your own words, what prompted you to reach out today? *

What would feel most supportive for you or your loved one right now? *

Wellness Preferences

These questions help us understand preferences. All education shared is non-medical and optional.

Are you open to learning about gentle, non-invasive wellness options such as essential oils, vitamins, or minerals for comfort and emotional ease?

Yes

Maybe

Not at this Time

Are there any sensitivities, preferences, or concerns we should be aware of?

Timing & Availability

Is this support needed urgently? *

Yes

Unsure

Preferred days/times for a conversation (if applicable):

Consent & Acknowledgement

Please acknowledge the following:

I understand Sacred Passage Support provides non-medical, complementary education and emotional support only.

I understand this service does not replace hospice, medical, or emergency care.

Anything Else You’d Like Us to Know?