Self Referral Application

Referring a Patient to Hospice

Who should be referred for Hospice Care?

Any patient who has a life-threatening illness with a prognosis of six months or less is the disease runs its normal course and is not receiving curative treatment should be referred to Hospice for supportive care. Hospice cares for and has expertise in the care of patients with many life-limiting illnesses and conditions, including but not limited to:

AIDS: increasing infections; self-care deficits; continued weight loss/weakness; medication no longer effective.

Alzheimer’s Disease: difficulty swallowing; inability to speak, dress, or feed self; loss of bowel and bladder control; progressive weight loss.

ALS (Lou Gehrig’s Disease): impaired swallowing/breathing; self-care deficits; muscle wasting rigidity; progressive weight loss.

Heart Disease: severe fatigue; difficulty breathing at rest; chronic fluid buildup; frequent hospitalizations.

Respiratory/Pulmonary Disease (end stage): difficulty breathing; poor control of symptoms; oxygen dependent; frequent hospitalizations.

Stroke: coma or persistent vegetative state; irreversible damage; inability to swallow; need for total care.


Parkinson’s Disease

Is Hospice the Answer?

Here are some signs of patients who may benefit from Hospice services:

Person is experiencing unintentional weight loss.

Person is experiencing pain that is not easily controlled or is poorly controlled.

Person is having an increased difficulty getting around.

Person has a decrease in appetite.

Person is sleeping excessively throughout the day.

Person has had several falls, or increased falls over a 3-6 month period.

Person needs increased assistance in daily activities such as dressing, bathing, and eating.

Person has wounds that are not healing.

Every patient is unique and should consult a doctor or call Hospice with questions about eligibility.

The earlier a patient is referred, the better quality of life can be provided.

The earlier a patient is referred, the more Hospice can do to help. Sadly, many people believe that hospice care is unavailable or inappropriate until the patient is confined to the home or bed. A great deal can be done, however, many months earlier to improve quality of life. Hospice can provide:

  • Expert pain and symptom management
  • Emotional and spiritual support to patient and loved ones
  • Assistance in organizing a patient’s personal affairs
  • Help in how to talk about the many difficult issues that arise at end-of-life
  • Help in dealing with unresolved issues that block communication
  • Support for the caregiver

Early referrals improve the quality of the patient’s life with the above interventions. The patient is more involved in making decisions; this in turn helps the family know that those difficult choices they need to make are what the family member desires. Decisions can be made before it is a moment of crisis.

Often the patient’s family or friends make the first call. However, a minister, nurse, friend, or even a next door neighbor can make the first call to Hospice.

Before actual admission, the patient’s physician must certify that the patient is medically appropriate for hospice care. Hospice will contact the physician to obtain this verification if the patient desires Hospice care.

To refer yourself or a loved one to Hospice, fill out the following form. All fields required unless otherwise noted. Please allow 24-48 hours for a team member to respond. You can also email us at with any questions. A member of our clinical staff will call you at the number you provide.

Are you referring for Hospice services or bereavement counseling?
Hospice servicesBereavement counseling

Are you referring yourself or another patient?
Self referralAnother patient

If referring another patient, please indicate your relationship:

Is there any other information you'd like us to know? (Optional)

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