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First name
Last name
Email
Phone
Preferred method of contact?
*
What support do you need?
*
Emotional support session
End-of-life Doula support
Companion visit
Practical comfort & planning
Legacy or memory project
Bereavement support
Not sure yet… I’d like guidance
Preferred session length ?
*
60 minutes
90 minutes
Ongoing support (doula/companion care)
How would you like the session?
*
In person (Staffordshire area)
Online (zoom/video call)
Phone call
When would you prefer your appointment ?
*
Morning
Afternoon
Evening
Flexible
Tell me a little bit about what you are looking for? (Share as much or as little as you’d like, this helps me understand how to support you).
Accessibility and comfort needs (Is there anything that makes you feel more comfortable during sessions?)
Where are you based? (Only needed for in-person support) town, postcode. Any notes in regards to parking or access.
How did you hear about me?
*
Google
Recommendation
Social media
Event/workshop
Other
Consent and agreement
*
“I understand that this service is non-medical and focused on emotional and practical support
“I agree to the privacy and confidentiality policy”
Send request
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