Self Assessment Questionnaire Take this self-assessment to see if hospice or palliative care is right for you. 1Self-Assessment 2Results Have you or a loved one been diagnosed with a serious, life-limiting illness?(Required) Yes No Has there been a recent change in this condition?(Required) Yes No Has this condition resulted in frequent trips in and out of the hospital?(Required) Yes No Have hospital visits become less effective?(Required) Yes No Have you or your loved one started to need more help to perform daily activities or manage this illness?(Required) Yes No Would you or your loved one like to focus on comfort, symptom management, and quality of life?(Required) Yes No From your answers it seems that hospice might be a good fit to help you or your loved one. Please reach out at 845-634-4974 or complete the form below and one of our trained staff will contact you. It may not yet be time for hospice care. If you would like to speak to one of our trained staff to learn more about how hospice may help in the future, Please reach out at 845-634-4974 or complete the form below and one of our trained staff will contact you.Name(Required) First Last Email(Required) Phone(Required)NameThis field is for validation purposes and should be left unchanged.
