JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Community Practitioners
A Sacred Passing is a Death Education and Community Care organization. We have a community home where people come to die accessing their right to Medical Aid in Dying and Voluntary Stopping of Eating and Drinking- Both which are legal option in Washington.
Roles Needed
Capacity Counseling
- a state licensed psychiatrist, psychologist, independent clinical social worker, advanced social worker, mental health counselor, or psychiatric advanced registered nurse practitioner
Consulting qualified medical provider
- Consult and confirm diagnosis
Attending qualified medical provider
-
Consults and writes the prescription
Catheter Insertion
- Assistance inserting a foley catheter for rectal administration. This is only the insertion of the catheter, no other care required. HCA, CNA, LNP, RN, MDs, DO
Resources
Washington State Death With Dignity Act
Voluntary Stopping of Eating and Drinking
DOH Forms
PSYCHIATRIC/PSYCHOLOGICAL CONSULTANT’S COMPLIANCE FORM
THE WASHINGTON DEATH WITH DIGNITY ACT: WASHINGTON STATE PSYCHOLOGICAL ASSOCIATION GUIDELINES FOR PSYCHOLOGICAL EVALUATIONS Revised April 2019
Consulting Provider Form
Attending Provider Form
After Death Reporting
Online Reporting
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
Your answer
Last Name
Your answer
Contact Email
Your answer
Contact Phone Number
Your answer
Role ( Details are in the links at the beginning of the form)
*
Rectal Catheter insertion
Consulting Medical Provider
Attending Medical Provider
Psych Consult
Required
Professional License Type
Your answer
Is your WA state license current?
*
Yes
No
Maybe
Website - if you want
Your answer
Other information that you would like to share
Your answer
Payments
*
I am willing to volunteer
I only accept cash, check or card
I only accept Insurance
I am open to all three
Other:
Required
Would you also like to be connected with End of Life Washington to be a volunteer with them in this same type of role?
Yes
Yes, but for more information and then i'll decide
No
Clear selection
Questions?
Your answer
We understand that to make the relationship legal, there must be a charge. Are you willing to do a base charge of the prices below?
*
$1.00
$25.00
Other:
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of A Sacred Passing.
Report Abuse
Forms
