Request appointment | S Nycole Beard

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Medication Other Not sure

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Which service are you interested in? ☐ Individual Coaching ☐ Trauma-Informed Coaching ☐ Relationship Coaching ☐ Couples Coaching ☐ End-of-Life Doula Support ☐ Family/Caregiver End-of-Life Support ☐ Grief and Bereavement Support ☐ I am unsure and would like help determining the best service

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Who are you seeking services for? ☐ Myself ☐ Myself and my partner ☐ A family member or loved one ☐ My family or caregiving system ☐ Other: ______________________

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Briefly describe what brings you here and the support you are seeking.

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What would you most like to be different as a result of receiving support?

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How soon are you hoping to begin services? ☐ As soon as possible ☐ Within 1–2 weeks ☐ Within the next month ☐ I am gathering information at this time

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Where are you physically located? City: ______________________ State: ______________________ Country: ______________________

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For Coaching Services: Which areas would you like support with? Select all that apply. ☐ Personal growth and life transitions ☐ Trauma-informed personal development ☐ Relationship patterns ☐ Communication and boundaries ☐ Couples or relationship concerns ☐ Stress management and life balance ☐ Confidence and self-trust ☐ Decision-making and clarity ☐ Grief or major life changes ☐ Accountability and goal achievement ☐ Other: ______________________

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Are you currently experiencing a mental health concern that significantly affects your ability to function day to day? ☐ No ☐ Yes ☐ Unsure ☐ Prefer to discuss privately

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Are you currently receiving psychotherapy or psychiatric care? ☐ No ☐ Yes ☐ Not currently, but I have in the past ☐ Prefer to discuss privately

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Are you seeking diagnosis, psychotherapy, trauma processing, or treatment of a mental health condition? ☐ No ☐ Yes ☐ Unsure

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Please confirm your understanding: ☐ I understand that coaching is a non-clinical service and is not psychotherapy, mental health treatment, crisis intervention, or a substitute for medical or psychiatric care.

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For Relationship or Couples Coaching:Is each person participating voluntarily? ☐ Yes ☐ No ☐ Unsure

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Is there currently physical violence, threats of violence, coercive control, stalking, or fear for anyone’s immediate safety within the relationship? ☐ No ☐ Yes ☐ Unsure ☐ Prefer to discuss privately

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What is the primary relationship concern you would like support with?

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For End-of-Life Doula Services:Who would receive end-of-life doula support? ☐ Myself ☐ Spouse or partner ☐ Parent ☐ Family member ☐ Friend or loved one ☐ Caregiver or family system

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Which best describes the current situation? ☐ Recently diagnosed with a serious or life-limiting illness ☐ Living with an advanced illness ☐ Receiving palliative care ☐ Enrolled in hospice ☐ Actively approaching end of life ☐ Anticipatory grief or family preparation ☐ Recent death and bereavement support ☐ Advance planning without a current terminal diagnosis ☐ Other: ______________________

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What type of support are you seeking? Select all that apply. ☐ Emotional support ☐ Education and preparation ☐ Advance care planning support ☐ Legacy or life-review work ☐ Family or caregiver support ☐ Vigil planning and bedside presence ☐ Comfort planning and non-medical support ☐ Grief and bereavement support ☐ Spiritual or meaning-centered support ☐ Resource navigation ☐ Other: ______________________

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Is the individual currently receiving medical, palliative care, or hospice services? ☐ No ☐ Yes ☐ Unsure If yes, please identify the type of service or organization, if known:

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Is there an urgent or rapidly changing situation that may require immediate support? ☐ No ☐ Yes ☐ Unsure If yes, please briefly explain:

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Are there cultural, spiritual, religious, family, or personal values you would like honored as part of your care? ☐ No ☐ Yes ☐ Unsure If yes, please share what feels important:

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Please confirm your understanding: ☐ I understand that end-of-life doula services are non-medical and do not replace physicians, nurses, hospice, emergency services, legal professionals, or licensed mental health treatment.

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Safety and Service Fit:Are you currently experiencing an immediate medical or mental health emergency? ☐ No ☐ Yes ☐ Unsure

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Are you currently having thoughts of suicide, seriously harming yourself, or harming another person? ☐ No ☐ Yes ☐ Prefer to discuss privately

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Is there anything else you would like me to know before I contact you?

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Acknowledgment:☐ I understand that submitting this prescreener does not establish a professional relationship or guarantee acceptance for services. I understand that I may be referred to another provider or level of care if my needs fall outside the scope of the services offered.

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