Don’t Duck the Conversation – Feedback Form Thank you for offering to share a little bit about your experience with us. Your comments help us to determine if we need to make any changes to the workbook to help serve you better. The information gathered from this form will be stored on our database. How did you find out about our Advance Care Planning Guide?* Family Member/Friend Hospice Northwest Website Newspaper Hospice Northwest Volunteer Family Doctor Palliative Care Worker Funeral Home Other If other - Please explainDo you currently utlizing any other services from Hospice Northwest or have you utilized any of our services in the past?* One-to-One Palliative Care Support Grapm One-to-One Grief and Bereavement Support Hearts and Hope Grief and Bereavement Support Group Circle of Friends Support Group Other If yes, please check with option(s) applyIf other - Please explainHow did you access our Advance Care Planning Guide?*I downloaded the guide from Hospice Northwest’s websiteI picked up a hard copy of the guide from Hospice Northwest’s officeI arranged for Hospice Northwest to mail me a copy of the guideOtherIf other, please explainBefore becoming aware of our Advance Care Planning Guide, had you ever considered writing your own Advance Care Guide?*NoYesOn a level from 0 to 10, 0 meaning no motivation, and 10 meaning strong motivation, how motivated were you to complete our guide?*012345678910Did you need to put any supports in place before you were ready to proceed with completing this guide, such as talking with a counselor, a clergy member, or your family doctor?*YesNoIf yes, please explainHas our Advanced Care Planning Guide been helpful to youYesNoWhat did you like/dislike about our guide's approach?*What was one thing that surprised you most about this process?If there was one question that you would have liked us to ask you, what would that be? Why?What have you learned from this process that will help you now or in the future?Is there anything else that you wish to share with us?Your informationPlease feel free to share your contact details with us. If you'd prefer to be anonymous just leave this section blank.Name First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneCellEmail Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.