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.
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Your Name *
Phone & Email Address *
Patient's Name *
Patient's Age *
What's your relationship to the patient? *
How is the patient most directly at-risk? *
How can we most directly help? *
What is the issue you need our help with? *
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.
Patient's Home Address
Patient's State Senator & State Representative
Hospital/Institution Name & Address
Attending Physician's Name
Length of Current Stay
Reason for Hospital/Institution Admittance
Is there a dispute about proper care for the patient? *
Does the patient have an Advanced Directive, Do-Not-Resuscitate (DNR) order, or POLST/MOLST in place? *
Has the patient appointed a Medical Power of Attorney? *
Who does the hospital treat as the medical decision-maker? *
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?
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.?
Additional comments:
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This form was created inside of Terri Schiavo Life & Hope Network.