Request Support

EOLCCA’s mission is to provide Californians with information and support to successfully navigate all legal end-of-life options. Whether you are seeking information for yourself, for a loved one, or are a healthcare professional looking to support your patients, EOLCCA is here to guide you through every aspect of the law and provide free support you need during this important journey.

Main Contact

Tell us about yourself
*Primary Contact Information for person submitting this Request Form on someone else's behalf

Client Contact Information

This area is to be completed by the person requesting support or by the Primary Contact person who is filling out the form on their behalf.
Client Name
Pronouns (optional)
Client Address
Is it ok to leave messages at this phone number?
Can we identify ourselves as 'End of Life Choices California' in a voicemail?
Briefly share how EOLCCA can help?

Illness & Care

Has your physician given you a terminal diagnosis with less than six months life expectancy?

Additional Information

Are you currently enrolled in hospice care?

Physician Information

Have you discussed your end-of-life choices with your physician?
How did you hear about us?
Checkboxes

End of Life Choices California's Privacy Policy



Who we are


Our website address is: https://endoflifechoicesca.org.



What personal data we collect and why we collect it


Comments


When visitors leave comments on the site we collect the data shown in the comments form, and also the visitor's IP address and browser user agent string to help spam detection. An anonymized string created from your email address (also called a hash) may be provided to the Gravatar service to see if you are using it. The Gravatar service privacy policy is available here: https://automattic.com/privacy/. After approval of your comment, your profile picture is visible to the public in the context of your comment.


Media


If you upload images to the website, you should avoid uploading images with embedded location data (EXIF GPS) included. Visitors to the website can download and extract any location data from images on the website.


Cookies


If you leave a comment on our site you may opt-in to saving your name, email address and website in cookies. These are for your convenience so that you do not have to fill in your details again when you leave another comment. These cookies will last for one year.


If you visit our login page, we will set a temporary cookie to determine if your browser accepts cookies. This cookie contains no personal data and is discarded when you close your browser.


When you log in, we will also set up several cookies to save your login information and your screen display choices. Login cookies last for two days, and screen options cookies last for a year. If you select "Remember Me", your login will persist for two weeks. If you log out of your account, the login cookies will be removed.


If you edit or publish an article, an additional cookie will be saved in your browser. This cookie includes no personal data and simply indicates the post ID of the article you just edited. It expires after 1 day.


Embedded content from other websites


Articles on this site may include embedded content (e.g. videos, images, articles, etc.). Embedded content from other websites behaves in the exact same way as if the visitor has visited the other website. These websites may collect data about you, use cookies, embed additional third-party tracking, and monitor your interaction with that embedded content, including tracking your interaction with the embedded content if you have an account and are logged in to that website.


How long we retain your data


If you leave a comment, the comment and its metadata are retained indefinitely. This is so we can recognize and approve any follow-up comments automatically instead of holding them in a moderation queue.


For users that register on our website (if any), we also store the personal information they provide in their user profile. All users can see, edit, or delete their personal information at any time (except they cannot change their username). Website administrators can also see and edit that information.


What rights you have over your data


If you have an account on this site, or have left comments, you can request to receive an exported file of the personal data we hold about you, including any data you have provided to us. You can also request that we erase any personal data we hold about you. This does not include any data we are obliged to keep for administrative, legal, or security purposes.


Where we send your data


Visitor comments may be checked through an automated spam detection service.


Your contact information


Any contact information or personal data gathered from inquiry forms is strictly for internal use only, and is not shared or sold.


Additional information


If you have questions, please contact us.


End of Life Choices California
153 S. Sierra Ave. #30
Solana Beach, CA 92075
(760) 636-8009
info@endoflifechoicesca.org