Client Intake & Consent Form

Keshnie Mathi is a certified counselor practicing in the area of transitional support for those dealing with palliative care, fatal diagnosis,end of life, grief, loss and bereavement. She supports from fatal diagnosis, into active death and assists the family through bereavement.

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* 1. Name of client

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* 2. At what email address would you like to be contacted?

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* 3. What is your relationship to the client if filling this in for them?

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* 4. Which services best suit the clients needs

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* 5. Does client consent to being contacted?

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* 6. Has client consented to receiving support during this time?

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* 7. Please list any concerns that I need to be aware of

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* 8. Please list any preferred times for sessions

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* 9. Please choose preferred method

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* 10. I consent to The Wellness Specialist reaching out to confirm and arrange counselling and support sessions in the areas of Palliative Care, End of Life, Grief, Loss, and Bereavement.

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