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 non-medical resources, including rooms in the homes of community members.  These spaces are not supported with medical personnel, but are supported by trained community care volunteers including doulas.  
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Email *
I would like to exercise my choice
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Guest Name *
Guest Phone Number *
City
Guest Support Person if applicable  (name)
Guest Support Person phone number
Diagnosed Illness *
Are you under a physician's care? if so please write their name and phone number below
Choice in which you want to exercise *
Have you been approved for Medical Aid in Dying?
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Are you under hospice care? *
If yes, please share the Hospice name and Contact person
Do you have your advance care documents completed?
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Do you have your disposition plans completed?
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Funeral Home Name and Contact *
I understand
Submit
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