Seeking a place to die
If you are in need of a safe location to exercise your end of life choice of Medical Aid in Dying (MAID) or Voluntary Stopping of Eating and Drinking (VSED) please complete this form. Please understand these are not medical facilities, but rooms in the homes of community members. These spaces are not supported with medical personal, but trained community care volunteers.
* Required
Email address
*
Your email
I would like to exercise my choice
less than 1 week from now
less than 1 month from now
less than 3 months from now
less than 6 months from now
within the year
.... at sometime, i am just inquiring right now
Clear selection
Guest Name
*
Your answer
Guest Phone Number
*
Your answer
City
Your answer
Guest Support Person if applicable
Your answer
Guest Support Person phone number
Your answer
Diagnosed Illness
*
Your answer
Are you under a physician's care? if so please write their name and phone number below
Your answer
Choice in which you want to exercise
*
Medical Aid in Dying
Voluntary Stopping of Eating and Drinking
Have you been approved for Medical Aid in Dying?
Yes
No
If no, do you need help starting the process?
Clear selection
Are you under hospice care?
Yes
No
Clear selection
If yes, which Hospice
Your answer
Do you have your advance care documents completed?
Yes
No
No, and I need help completing them
Clear selection
Do you have your disposition plans completed?
Yes
No
No, and I need help completing them
Clear selection
I understand
a volunteer will call me to talk about further details
I will have to sign some liability paperwork (because, you know, systems are always at play)
Send me a copy of my responses.
Submit
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