Resource Guide
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Health 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)    
     
Health Care Organization
Name*

Type of Organization: (Check all that apply)
Assisted Living
Community Health Center
Extended Care Facility
Home Care
Hospice
Hospital
Nursing Home
Visiting Nurse Service/Home Health
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.
Address  
City
State Zip
Phone Fax
Contact
to be listed in directory/
Title*
Contact
Phone*
Email* Fax
Internet/
Web Page
END OF LIFE CARE PROGRAM/SERVICES
Alzheimer's/Dementia Day Program Palliative Care Unit
Child Life Specialist Palliative Care Service
Home Care Pediatric Hospice Service
Hospice Care Respite Care
   
Other
EDUCATION/INFORMATION
Advanced Care Planning
Patient/Family library including End-of-Life Resources
Other
SPECIALIZED PROGRAMS/SYMPTOM MANAGEMENT FOR LIFE THREATENING CONDITIONS
AIDS Oncology Home Care
Bloodless Medicine Specialized Geriatrics
Cancer Transplants
Pain Service or Clinic WOCN (Wound, Ostomy, Continence Nurse Specialist)
   
Other
CLINICAL TRIALS    
Pain Associated with Life Threatening Illness
End of Life Specific    
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
Other
Caregiver Support Groups
Health Professionals
Family Members
Other English Other Language
           
MENTAL HEALTH RELATED TO LIFE THREATENING ILLNESS
Illness, Death and Grief Counseling
Specialized Medical/Life Threatening Condition
Specialized Geriatric Services
Other
SPIRITUALITY
Chaplain Services with specific End-of-Life Training
Other
HOSPICE
Residential Facility
Pediatric Hospice
Other
COMPLEMENTARY HEALTH
Acupuncture
Massage
Meditation
Stress Reduction Program
Other
LANGUAGE/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
REFERRAL SERVICES
Referral Service including End-of-Life Issues: phone
 
FINANCIAL ASSISTANCE
Patient/Family Funds Specific to End-of-Life Services
Free Care
Mass Health
Sliding Fee Scale
Financial Aide Counselor
Other
 
TRANSPORTATION/LODGING
Hotel Discounts for Families of Patients
Patient/Family Accommodations
Valet Parking
Public Transportation
Other
 
HANDICAPPED ACCESSIBLE
Coordinated Handicapped Care Service
 
Contact
Number
 
Contact
Dept.
TTDY
 
 
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