Resource Guide
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Community care survey
   
Please complete this survey regarding services specifically
geared toward individuals living with life threatening illness.
(people who are living with illness in or nearing terminal phase)
 
Please indicate all services your organization provides for
end-of-life care.
(*Required)    
     
Organization
Name*

TYPE OF ORGANIZATION: (Check all that apply)
Bereavement Support
Community Center
Counsel on Aging
Educational Institution/Organization
Elder Services
Faith Based Services
Funeral/Burial
Government Agency
Legal/Financial Organization
Multicultural Center
Multi-Service Agency
State/Regional Association or Coalition
Voluntary Health Organization/Association
Other
Please provide us with a 2-4 sentence description of your program and services EXACTLY as you would like it to appear in the guide.
POPULATION SERVED (if applicable)
Specific
Cultural
or Ethnic
Group(s)
Specific
Illness
Disabilty
Age
Address
City
State Zip
Phone Fax
Internet/
Web Page
Contact
to be listed in directory/
Title*
Contact
Phone*
Email*
 Fax
EDUCATION/INFORMATION
Medical Information Services
Advanced Care Planning
Caregiver Education
Professional
Family
Internet Access
Internet Training Sessions/Services
Library Resources
Patient Advocacy Programs
Provide Medical Education Workshops
Pamphlet/Leaflets on End of Life or Chronic Health Condition
Please Specify
Other
COUNSELING WITH END-OF-LIFE/GRIEF FOCUS
Individual English Other Language
Family English Other Language
Children English Other Language
Bereavement English Other Language
General
Type of Loss
SUPPORT GROUPS
General Cancer English Other Language
Ovarian Cancer English Other Language
Breast Cancer English Other Language
Prostate Cancer English Other Language
Lung Cancer English Other Language
AIDS/HIV English Other Language
Alzheimer's English Other Language
Heart Disease English Other Language
Lung Disease English Other Language
Transplant English Other Language
Bereavement English Other Language
General/Adult
Parental
Children
Adolescent
Lesbian/Gay Partner Support
Suicide
Homicide
Traumatic Death
Pregnancy Loss/Newborn Death
Other
Caregiver Support Groups
Health Professionals
Family Members
Other English Other Language
SPECIALIZED PROGRAMS
Alzheimer's
  Day Care Program
Parish Nurse Program
Respite Care
Home Care Support Services
Medical Clinic/Services
Type of Program
Other
COMPLEMENTARY THERAPIES
Acupuncture
Exercise Therapy or Program
Massage Therapy
Meditation or Stress Reduction Program
Reiki
Yoga
Therapeutic Touch
Wellness Programs
Please Specify
Other
SPIRITUAL CARE
For Life Threatening Illness
Type of Program
Grief
Type of Program
HOME SUPPORTS
Companion
Homemaker
Meals
Personal Care
Shopping/Errands
Volunteer
Pet Care
Other
LEGAL ASSISTANCE
Advise/Assistance Specific to Illness and Death
Estate Planning
Free Legal Assistance
FINANCIAL ASSISTANCE
General Financial Advise/Assistance
Benefits Counseling
  Medicare
  Social Security
 
Other
 
Information and Referral Services
Free Care/Sliding Fee Scale
Mass Health
Patient/Family Assistance Fund
FUNERAL PLANNING/ASSISTANCE
  
Pre-need Planning
Merchandise(caskets,urns,headstones,etc)
Burial
Cremation
Emergency/Out-of-town Occurrences
Other
TRANSPORTATION/LODGING
Hotel Discounts for Families of Patients
Patient/Family Accommodations
Valet Parking
Public Transportation
Assistance with Transportation
  HANDICAPPED ACCESSIBLE
Coordinated Handicapped Care Service
 
Contact
Number
 
Contact
Dept.
TTDY
INTERPRETER SERVICES
American Sign Language
ATT Language Line
Albanian Italian
Amharic/Tigrinya Japanese
Arabic Korean
Armenian Laotian
Cambodian Pakistani
Cape Verdian Polish
Chinese Portuguese
French Russian
German Spanish
Greek Turkish
Haitian/Creole Vietnamese
Hindi/Bengali  
Other

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