EOLCNY Intake Form for Support and Medical Aid in Dying Support

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This Intake Form is for all incoming inquiries from community members looking for support. This form includes Advance Care Planning and Advance Directives, Medical Aid in Dying (MAiD), Voluntarily Stopping Eating and Drinking (VSED), and Palliative / Hospice Care.

A special thank you to The Academy of Aid-in-Dying Medicine for their clinical support.

Notes on our Support and Referral Processes:

Our program serves as an information and resource connection point for New York state. Our program aims to respond to you within 3-4 days. Our services are free of charge.

For Medical Aid in Dying support, please complete all MAiD Supplemental Questions. Once we confirm the details of your intake with you, we reach out to providers within your area. Once we hear back from providers, we will make the connection. This may require some time. Provider information is confidential and not shared widely. If you have any questions, please reach out to nathalie@eolcny.org.

If you require assistance completing this intake, please reach out to 212-726-2010 or nathalie@eolcny.org to arrange support.

Email *

First and Last Name of Patient *

Date of Birth and Age *

Gender and Pronouns *

Address *

Direct Phone Number *

Caregiver Information- Phone, Email Address, and Relationship to Patient

Preferred Method of Communication

What support are you looking for? *

Advance Care Planning and Advance Directives

Medical Aid in Dying (must complete supplemental questions)

Voluntarily Stopping Eating and Drinking (VSED)

Palliative / Hospice Care

Other:

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