Tara Home Residency Application

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For terminal patients who have already been approved by hospice and wish to die at Tara Home.

Patient's Full Legal Name *

Date of Birth *

YYYY

In need of immediate placement? *

Tara Home residencies are up to 8 weeks in duration.

Yes

Required

Currently residing at

Home

Care Facility

Other:

Required

Patient's Address *

Street Address, City, State, Zip, Country

Patient's Phone Number *

Patient's Email

Primary Language *

Religion / Spiritual Tradition *

Please describe your history with Buddhism, meditating, or other spiritual traditions

Why do you want to die at Tara Home? *

What do you wish to explore in conversations with Tara Home volunteers. *

REFERRING AGENCY/FACILITY (Medical/Hospice)

Sex *

Female

Male

REFERRING NAME

Full name and title of referring physician &/or Hospice Case Manager

PERSONAL / FAMILY CONTACT NAME

Full name of person submitting this form as point person and responsible for primary care.

RELATIONSHIP

Relationship of contact person to patient. Also please describe other relationships in patient's life (family, friends) especially those who will be directly involved in care.

Contact Phone Number *

Contact Email *

Contact Address *

Street Address, City, State, Zip, Country

Terminal Diagnoses

Please list your medical history with dates, including terminal diagnoses

Recent Treatments, Surgeries and Dates

Please list your treatment and surgical history, including dates

Current Medications

Please list your current medications, including dosage

SYMPTOMS *

Check all that apply

Difficulty Swallowing

Difficulty Breathing

Pain

Nausea/Vomiting

Diarrhea

Rash/Itching

Other Symptoms

TREATMENT *

Check all that apply

Radiation

Infusions

Wound Care

Oxygen

Other Treatments

MOBILITY *

Check all that apply

Independent

Assistance

Wheelchair

Bed Bound

Other Mobility Issues

TOILETING *

Check all that apply

Independent

Assistance

Incontinent Bladder

Incontinent Bowel

Foley Catheter

Atomies

Required

ADDICTIONS *

Check all that apply

Current Addict

Past Addict

Never Addicted

Alcohol

Hard Drugs (Narcotics, Meth, etc)

Smoking (Tobacco, Vaping, etc)

Please elaborate on any history of substance abuse.

MENTAL STATE *

Check all that apply

Clear/Oriented

Short-term Memory Loss

Confused

Mild Dementia

Severe Dementia

Required

Please elaborate on psychological history. *

Submission Agreement

By clicking and submitting this time-stamped form, I acknowledge that:

1 - DNR (Do Not Resuscitate Order) and MORTUARY ARRANGEMENTS are REQUIRED for Admission.

2 - There must be a Durable Power of Attorney for Health Care on file with Hospice prior to Admission.

I agree

Required

Submit

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This form was created inside of Tara Home.