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Companion Presence Service – Intake Form

The purpose of this intake form is to understand the individual’s needs, preferences, and expectations, and to ensure that the Companion Presence service is an appropriate and supportive fit for everyone involved.

Basic Information

Multi-line address
Best method of contact:

About the Request

Who is this service for?
How would you describe the individual’s current living situation?

Preferences & Comfort

What type of companionship feels most supportive? (check all that apply)

Scheduling & Frequency

Preferred frequency:
Preferred length of visits:

Practical Consideration

Where will visits primarily take place?

Important Notes

Important Acknowledgement

The Companion Presence Service provides non-medical, non-therapeutic companionship only. It does not include personal care, medical assistance, counseling, or emergency services. This service is intended to offer respectful presence and conversation, not professional health or mental health care.


By proceeding, you acknowledge responsibility for determining suitability and agree that Anna Mandala is not liable for outcomes beyond the scope of companionship as described.

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Date
Year
Month
Day

Thank you for your thoughtful responses.


Each request is reviewed personally to ensure alignment, care, and integrity in the work.

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