Free Confidential Assessment

Instructions: “Please check all that apply for each the following situations:

Sometimes my family, friends and loved ones do not listen to me or understand how I feel.

I want my voice to be heard.

I want to have all of my affairs in order (healthcare, financial, legal, etc.)

I want to minimize the amount of stress on my family.

I do not want to be a financial burden to my family.

I want my loved ones to be at peace.

I want to spend my final days/weeks/months at home.

I want to minimize the amount of stress on others.

I want to receive hospice services as soon as it’s possible.

I want to be treated with respect even when I cannot speak for myself.

I have wishes and desires that I want honored after I transition.

I want to maintain a certain level of quality in my life.

I want the chance to share my life story with others.

I want to keep connected to my faith and/or faith community.

I do not want to transition alone.

I want to choose where I transition (home, hospital, hospice center, etc.)

I agree to the Terms of UseView Terms of Use

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