Crisis Lifeline
The Terri Schiavo Life & Hope Network's Crisis Lifeline. Information shared here is strictly confidential, and will not be shared with third-parties without consent.
Your Name *
Your answer
Phone & Email Address *
Your answer
Patient's Name *
Your answer
Patient's Age *
Your answer
What's your relationship to the patient? *
Your answer
How is the patient most directly at-risk? *
How can we most directly help? *
What is the issue you need our help with? *
Your answer
Is the patient conscious? *
Is the patient responsive? *
Does the patient have decision-making capacity? *
Patient's current condition *
Include any temporary conditions or underlying medical history.
Your answer
Patient's Home Address
Your answer
Patient's State Senator & State Representative
Your answer
Hospital/Institution Name & Address
Your answer
Attending Physician's Name
Your answer
Length of Current Stay
Your answer
Reason for Hospital/Institution Admittance
Your answer
Is there a dispute about proper care for the patient? *
Your answer
Does the patient have an Advanced Directive, Do-Not-Resuscitate (DNR) order, or POLST/MOLST in place? *
Your answer
Has the patient appointed a Medical Power of Attorney? *
Who does the hospital treat as the medical decision-maker? *
Your answer
Has the patient or family heard a physician or the institution use any of the following terms? *
Have the patient's physicians or facility used terms like "coma," "persistent vegetative state (PVS)," or "brain death?" In what contexts?
Required
Has the patient or family received written notice of an institution's Ethics Committee being involved in decision-making? *
Has the patient or family requested medical records? *
Describe the patient and family dynamics:
Is the patient on good terms with family members? Married, divorced, how many adult children, any other family in the area, etc.?
Your answer
Additional comments:
Your answer
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This form was created inside of Terri Schiavo Life & Hope Network.