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Request an Advance Care Planning Appointment

Complete the form below to request an appointment with an Honoring Choices Facilitator.

We respect your privacy.
The information that you provide via this website will be strictly confidential and is intended only for the use of Goshen Health in providing care and services to you.

First Name:

Last Name:

Email:

Phone:

( ) -

Address:

City:

State:

ZIP:

Preferred appointment time (required):

Morning
Afternoon
Evening
No preference

Do you have internet access and a device with video and audio capabilities? (required):

Yes
No

It is important to have a family member or close friend, that will be involved with your health care decisions, attend the appointment. Please enter their name and relationship to you. (required):

Do you need a interpreter? (required):

Yes
No

If so, please enter the language. We will do our best to accommodate your needs.:

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Advance care planning is for adults of all ages

Receive the medical care you want and ensure your loved ones know your wishes.
In the appointment, we’ll help you:

Create an advance care plan
Complete advance directives
Designate a health care representative

Invite a family member or close friend

Note, it is important to have a family member or close friend that will be involved with your health care decisions attend the appointment.

Where: virtual appointment via Zoom or in-person
Cost: Free, but an appointment is required
Questions: Call (574) 364-2288

Documents for end-of-life care

Written documents give clear instructions about the kind of care you want at the end of life. By writing down your wishes, you can help your loved ones and doctors understand and follow your choices. That’s important if you are unable to make decisions or communicate for yourself.