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  <div class="gform-body gform_body">
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      <li id="field_1_19"
        class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
        data-js-reload="field_1_19"><img loading="lazy" decoding="async" src="/wp-content/uploads/2025/01/helpful-nurse.jpg" style="margin-bottom:15px;">
        <h3>You don’t have to take this journey alone.</h3>
        <p>This 60-second assessment will help you determine whether hospice or palliative care is the right choice. For eligible patients, hospice is 100% covered by Medicare, with most Medicaid and commercial insurance plans also providing
          coverage. Anyone can refer a patient to hospice, and the evaluation is free. We serve select counties in North Carolina and South Carolina.</p>
      </li>
      <li id="field_1_15" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
        data-js-reload="field_1_15"><label class="gfield_label gform-field-label gfield_label_before_complex">Have you or a loved one been diagnosed with one or more of the following conditions? (Check all that apply)</label>
        <div class="ginput_container ginput_container_checkbox">
          <ul class="gfield_checkbox" id="input_1_15">
            <li class="gchoice gchoice_1_15_1"><input class="gfield-choice-input" name="input_15.1" type="checkbox" value="Alzheimer’s, dementia, other memory care disorder" id="choice_1_15_1"><label for="choice_1_15_1" id="label_1_15_1"
                class="gform-field-label gform-field-label--type-inline">Alzheimer’s, dementia, other memory care disorder</label></li>
            <li class="gchoice gchoice_1_15_2"><input class="gfield-choice-input" name="input_15.2" type="checkbox" value="Cancer" id="choice_1_15_2"><label for="choice_1_15_2" id="label_1_15_2"
                class="gform-field-label gform-field-label--type-inline">Cancer</label></li>
            <li class="gchoice gchoice_1_15_3"><input class="gfield-choice-input" name="input_15.3" type="checkbox" value="Heart disease" id="choice_1_15_3"><label for="choice_1_15_3" id="label_1_15_3"
                class="gform-field-label gform-field-label--type-inline">Heart disease</label></li>
            <li class="gchoice gchoice_1_15_4"><input class="gfield-choice-input" name="input_15.4" type="checkbox" value="Lung disease" id="choice_1_15_4"><label for="choice_1_15_4" id="label_1_15_4"
                class="gform-field-label gform-field-label--type-inline">Lung disease</label></li>
            <li class="gchoice gchoice_1_15_5"><input class="gfield-choice-input" name="input_15.5" type="checkbox" value="Brain/Spinal Cord/Nerve condition/Muscular disorder" id="choice_1_15_5"><label for="choice_1_15_5" id="label_1_15_5"
                class="gform-field-label gform-field-label--type-inline">Brain/Spinal Cord/Nerve condition/Muscular disorder</label></li>
            <li class="gchoice gchoice_1_15_6"><input class="gfield-choice-input" name="input_15.6" type="checkbox" value="Liver disease" id="choice_1_15_6"><label for="choice_1_15_6" id="label_1_15_6"
                class="gform-field-label gform-field-label--type-inline">Liver disease</label></li>
            <li class="gchoice gchoice_1_15_7"><input class="gfield-choice-input" name="input_15.7" type="checkbox" value="Kidney disease" id="choice_1_15_7"><label for="choice_1_15_7" id="label_1_15_7"
                class="gform-field-label gform-field-label--type-inline">Kidney disease</label></li>
            <li class="gchoice gchoice_1_15_8"><input class="gfield-choice-input" name="input_15.8" type="checkbox" value="AIDS" id="choice_1_15_8"><label for="choice_1_15_8" id="label_1_15_8"
                class="gform-field-label gform-field-label--type-inline">AIDS</label></li>
            <li class="gchoice gchoice_1_15_9"><input class="gfield-choice-input" name="input_15.9" type="checkbox" value="Other disease" id="choice_1_15_9"><label for="choice_1_15_9" id="label_1_15_9"
                class="gform-field-label gform-field-label--type-inline">Other disease</label></li>
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        data-js-reload="field_1_16"><label class="gfield_label gform-field-label gfield_label_before_complex">Are you or a loved one experiencing</label>
        <div class="ginput_container ginput_container_checkbox">
          <ul class="gfield_checkbox" id="input_1_16">
            <li class="gchoice gchoice_1_16_1"><input class="gfield-choice-input" name="input_16.1" type="checkbox" value="unexpected weight loss" id="choice_1_16_1"><label for="choice_1_16_1" id="label_1_16_1"
                class="gform-field-label gform-field-label--type-inline">unexpected weight loss</label></li>
            <li class="gchoice gchoice_1_16_2"><input class="gfield-choice-input" name="input_16.2" type="checkbox" value="shortness of breath, even when resting" id="choice_1_16_2"><label for="choice_1_16_2" id="label_1_16_2"
                class="gform-field-label gform-field-label--type-inline">shortness of breath, even when resting</label></li>
            <li class="gchoice gchoice_1_16_3"><input class="gfield-choice-input" name="input_16.3" type="checkbox" value="frequent falls" id="choice_1_16_3"><label for="choice_1_16_3" id="label_1_16_3"
                class="gform-field-label gform-field-label--type-inline">frequent falls</label></li>
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                class="gform-field-label gform-field-label--type-inline">spending more time confined to bed or a chair</label></li>
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        data-js-reload="field_1_18"><label class="gfield_label gform-field-label gfield_label_before_complex">Do you or a loved one need more help</label>
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            <li class="gchoice gchoice_1_18_1"><input class="gfield-choice-input" name="input_18.1" type="checkbox" value="bathing" id="choice_1_18_1"><label for="choice_1_18_1" id="label_1_18_1"
                class="gform-field-label gform-field-label--type-inline">bathing</label></li>
            <li class="gchoice gchoice_1_18_2"><input class="gfield-choice-input" name="input_18.2" type="checkbox" value="dressing" id="choice_1_18_2"><label for="choice_1_18_2" id="label_1_18_2"
                class="gform-field-label gform-field-label--type-inline">dressing</label></li>
            <li class="gchoice gchoice_1_18_3"><input class="gfield-choice-input" name="input_18.3" type="checkbox" value="getting out of bed" id="choice_1_18_3"><label for="choice_1_18_3" id="label_1_18_3"
                class="gform-field-label gform-field-label--type-inline">getting out of bed</label></li>
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                class="gform-field-label gform-field-label--type-inline">walking</label></li>
            <li class="gchoice gchoice_1_18_5"><input class="gfield-choice-input" name="input_18.5" type="checkbox" value="preparing and/or eating meals" id="choice_1_18_5"><label for="choice_1_18_5" id="label_1_18_5"
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          <ul class="gfield_checkbox" id="input_1_17">
            <li class="gchoice gchoice_1_17_1"><input class="gfield-choice-input" name="input_17.1" type="checkbox" value="started or increased pain medication" id="choice_1_17_1"><label for="choice_1_17_1" id="label_1_17_1"
                class="gform-field-label gform-field-label--type-inline">started or increased pain medication</label></li>
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                class="gform-field-label gform-field-label--type-inline">made more frequent trips to the doctor</label></li>
            <li class="gchoice gchoice_1_17_3"><input class="gfield-choice-input" name="input_17.3" type="checkbox" value="visited the ER or been hospitalized for the same symptoms in the past six months" id="choice_1_17_3"><label for="choice_1_17_3"
                id="label_1_17_3" class="gform-field-label gform-field-label--type-inline">visited the ER or been hospitalized for the same symptoms in the past six months</label></li>
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        data-js-reload="field_1_5"><label class="gfield_label gform-field-label" for="input_1_5">Has the doctor given a life expectancy of 6 months or less?<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
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        <div class="ginput_container ginput_container_email"><input name="input_11" id="input_1_11" type="email" value="" class="large" aria-required="true" aria-invalid="false"></div>
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        data-js-reload="field_1_13"><label class="gfield_label gform-field-label" for="input_1_13">County where you need service. We service select counties in NC &amp; SC.<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
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            <option value="New Hanover County, NC">New Hanover County, NC</option>
            <option value="Brunswick County, NC">Brunswick County, NC</option>
            <option value="Columbus County, NC">Columbus County, NC</option>
            <option value="Horry County, SC">Horry County, SC</option>
            <option value="Marion County, SC">Marion County, SC</option>
            <option value="Georgetown, SC">Georgetown, SC</option>
            <option value="Bladen County, NC">Bladen County, NC</option>
            <option value="Pender County, NC">Pender County, NC</option>
            <option value="Onslow County, NC">Onslow County, NC</option>
            <option value="Duplin County, NC">Duplin County, NC</option>
            <option value="Other NC">Other NC</option>
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  <div class="cm-hipaa-forms-prepend">
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        class="cm-hipaa-privacy-statement-link"><a href="https://lifecare.org/about-us/privacy-policies/" target="_blank">I agree to the HIPAA FORMS Service Privacy Statement</a></span></div>
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 * YOU DON’T HAVE TO TAKE THIS JOURNEY ALONE.
   
   This 60-second assessment will help you determine whether hospice or
   palliative care is the right choice. For eligible patients, hospice is 100%
   covered by Medicare, with most Medicaid and commercial insurance plans also
   providing coverage. Anyone can refer a patient to hospice, and the evaluation
   is free. We serve select counties in North Carolina and South Carolina.

 * Have you or a loved one been diagnosed with one or more of the following
   conditions? (Check all that apply)
    * Alzheimer’s, dementia, other memory care disorder
    * Cancer
    * Heart disease
    * Lung disease
    * Brain/Spinal Cord/Nerve condition/Muscular disorder
    * Liver disease
    * Kidney disease
    * AIDS
    * Other disease

 * Are you or a loved one experiencing
    * unexpected weight loss
    * shortness of breath, even when resting
    * frequent falls
    * spending more time confined to bed or a chair

 * Do you or a loved one need more help
    * bathing
    * dressing
    * getting out of bed
    * walking
    * preparing and/or eating meals

 * Have you or a loved one
    * started or increased pain medication
    * made more frequent trips to the doctor
    * visited the ER or been hospitalized for the same symptoms in the past six
      months

 * Has the doctor given a life expectancy of 6 months or less?*
   YesNoNot Sure
 * I'm filling out this form on behalf of*
   a family membera friendmyself
 * Family Member's name*
   
 * Your name*
   
 * Your Email Address*
   
 * Your Phone
   
 * County where you need service. We service select counties in NC & SC.*
   New Hanover County, NCBrunswick County, NCColumbus County, NCHorry County,
   SCMarion County, SCGeorgetown, SCBladen County, NCPender County, NCOnslow
   County, NCDuplin County, NCOther NC
 * Specify County (If Other)*
   
 * 


I agree to the HIPAA FORMS Service Privacy Statement I agree to the HIPAA FORMS
Service Privacy Statement
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800.733.1476




OUR MISSION:

Lower Cape Fear LifeCare is a nonprofit organization dedicated to providing
access to the highest quality LifeCare, education, and supportive services to
our patients, their families, and the communities we serve.


PATIENT REFERRAL

910.796.7937
800.207.6908
FAX:  910.796.7903
MAKE A REFERRAL


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Lower Cape Fear LifeCare
1414 Physicians Drive
Wilmington, NC 28401
910.796.7900 or 800.733.1476
FAX: 910.796.7901

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On January 1, 2020, Lower Cape Fear Hospice formally changed its name to Lower
Cape Fear LifeCare to better represent the spectrum of care and support they
provide those in our community.

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Lower Cape Fear LifeCare
© Lower Cape Fear LifeCare 2025
(formerly Lower Cape Fear Hospice)
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