Terminal Illness Counseling Intake Form

Supporting clients through a terminal illness diagnosis requires deep compassion, clinical expertise, and careful documentation. This terminal illness counseling intake form is designed for therapists, counselors, social workers, and palliative care professionals who provide emotional and psychological support to individuals and families navigating life-limiting diagnoses.

Why mental health support matters in terminal illness care

A terminal diagnosis brings profound emotional, spiritual, and practical challenges. Clients may experience grief, anxiety, depression, existential distress, and uncertainty about the future. Mental health professionals play a vital role in helping clients process their diagnosis, make informed decisions about their care, strengthen relationships, and find meaning during this sacred time.

This intake form creates a foundation for person-centered, holistic counseling by gathering essential information about the client's diagnosis, treatment journey, support system, emotional needs, legacy wishes, and end-of-life preferences—all in a respectful, organized format.

What this form helps you collect

The template guides clients through sharing their medical background, current diagnosis and prognosis, treatment decisions, emotional and spiritual concerns, family dynamics, legacy and meaning-making goals, advance care planning status, and immediate counseling needs. It balances clinical thoroughness with sensitivity, giving therapists the context needed to provide trauma-informed, dignity-centered care.

Paperform makes it easy to create forms that feel warm and human rather than clinical and cold. You can customize fonts, colors, and layouts to match your practice's tone, add empathetic language and helpful descriptions, and use conditional logic to show or hide questions based on each client's unique circumstances.

Streamline your intake process with automation

Once a client completes your intake form, Stepper (stepper.io) can automatically create a new client record in your practice management system, send a personalized welcome email, schedule follow-up reminders, notify your clinical team, and update your care coordination tools—all without manual data entry.

For therapists in private practice, hospice settings, palliative care programs, and cancer support centers, this form template helps you begin the therapeutic relationship with clarity, compassion, and respect for each client's journey.