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Client Intake Form

Help us understand your needs so we can provide personalized support tailored to you.

Section 1: Basic Information

Full Name *

Phone *

Email *

City *

Section 2: Who Needs Support?

Select One *

Section 3: Services Needed

Companionship Emotional Support Grief Support Anxiety / Depression Support Daily Living Assistance Respite Care Transportation On Eagle's Wings Program SOAR Program

Section 4: Current Situation

Please describe your current situation and what kind of support you are looking for. *

Section 5: Preferred Support Level

How often would you like support? *

Section 6: Timeline

When would you like to start? *

Section 7: Additional Details

Is there anything else we should know?

Section 8: Consent

I understand that Elev8ed Health and Wellness provides non-medical, supportive services. *

Thank you for reaching out!

We have received your intake form and will contact you within 24–48 hours to discuss your needs and next steps. We look forward to supporting you on your journey.

Something went wrong with your submission.

Please try again or contact us directly at 219-389-9959 or elev8edhealthandwellness@gmail.com.

What Happens Next?

After submitting your intake form, Nicole will reach out within 24–48 hours to discuss your responses, answer any questions, and schedule an initial consultation. This is your opportunity to learn more about how we can support you.

Elev8ed Health & Wellness

A faith-based practice rooted in connection, compassion, and transformation.

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