Mahogany Home Health & Hospice - Hospice Care

1

Who are you seeking hospice care for?* This field is required.Select one

My parent

My spouse or partner

Another family member

I’m gathering information for the future

Myself

2

Has your loved one been diagnosed with a serious or terminal illness?* This field is required.Select one

Yes, they have a terminal diagnosis

Yes, they have a serious illness and declining health

Not officially, but their health has significantly declined

I'm not sure

3

What are the primary goals of care right now?* This field is required.Select all that apply and click NEXT →

Comfort and quality of life

Pain and symptom relief

Emotional and family support

I’m unsure and need guidance

4

Is your loved one currently receiving curative or aggressive treatment?* This field is required.Select one

No, comfort care only

Yes, they are considering stopping treatment

Yes, they want to continue aggressive treatment

I’m not sure

5

Where is your loved one currently living?* This field is required.Select one

At home

Assisted living facility

Nursing facility

Hospital

Other

7

How soon do you feel hospice support may be needed?Select one

Immediately

Within the next few weeks

Within the next few months

Just gathering information

8

What is your name?* This field is required.Enter your first and last name

First Name

Last Name

9

What is your email address?* This field is required.Enter your best email address

10

What is your phone number?Enter your phone number

Area Code

Phone Number

11

Terms and Conditions* This field is required.

12

Sender