Verified end-of-life doula and bedside-attendant request for mentoring form – American Clinicians Academy on Medical Aid in Dying

Thank you for your interest in becoming part of our doula and bedside attendant referral system. We look forward to your unique addition to expanding and improving the care of aid-in-dying patients and their families.

Once you or the Academy have identified an appropriate aid in dying client to work with, we will provide you with mentoring from an experienced Academy clinician who will support you through the case. Mentors will connect with mentees several times via phone or video call, to discuss and review best practices before the death, and to debrief after. A mentor will also be available via phone, during the death, to provide support.

This mentoring is provided solely to foster a learning environment and is not intended to provide any care or any monitoring of patients. (Please remember that patient information is protected)

The Academy requires completion of this mentoring process before any referrals can be offered, no matter what level of experience or what credentials you have. The Academy’s goal, through this process, is to ensure the integrity of our Patient to End-of-Life-Doula and Bedside-Attendant Referral System and to support the attentive care that our patients require. We have found that many of our mentees feel well supported and grow from this fertile opportunity.

After this death, once you and your mentor both feel your competence and confidence are well established, your name and practice information will go into the Academy’s End-of-life-Doula and Bedside-Attendant Referral System, which we will use for patient referrals.

*If you do not currently have an appropriate aid-in-dying client to work with, the Academy will keep careful and close track of patient clients who may need this care, and contact you quickly if we identify anyone in your service area for you and your mentor to work with. Remember that this may take some time, months even, as there may not be many clients who need this care in your area. We will have you on our radar!!

*If you identify an appropriate client, please send us an email at [email protected] with the subject “Client identified, ready for a mentor”, ASAP, so we can connect you promptly.

Again, thank you so much, and stay tuned!

Name*
First Last
I practice in an American state where medical aid in dying is legal.*
- yes
Email*
Best phone contact*
May we text this number?*
- yes
- no
Practice Address (please choose state from drop-down)*
Street Address City State ZIP Code
What is your service area? e.g. "within 50 miles of Berkeley" or "within my zip code"*
Please briefly tell us about any other training, certification, or experience with end-of-life care you have.*
Are you currently working with, or will you soon have a legally qualified aid-in-dying client?*
- yes
- no
Please add any additional information that may be relevant to your mentor.
Academy Mentoring Agreement*
I understand and consent to this agreement
ACAMAID clinician and/or its representatives do not vet or review certifications of end-of-life doulas or other bedside attendants. We are not in any way responsible for the care provided. By signing this form you have consented, and agree that you will not hold ACAMAID or its representatives responsible for any actions or omissions during the care provided. ACAMAID's role is solely that of a mentoring and referral system and not that of a health care provider.
Academy Privacy Agreement*
I understand and consent to this agreement
ACAMAID clinicians and mentees agree to maintain patient/client privacy. In the interest of fostering a learning environment, you may discuss details of cases without using any personally identifying, or clinically irrelevant information such as names, and addresses.