Wish Request Form

Request a wish

A final wish may be requested for a person who:

Wish recipient diagnosed with a life-limiting condition and/or a prognosis of less than 12 months; and

Requires specialist transport to visit a place of personal significance due to medical needs, mobility limitations or logistical barriers.

To ensure each wish is carried out safely and with dignity, the recipient’s attending clinician must approve the wish. This confirms that the individual is medically able to undertake the journey, taking into account their health status and diagnosis. The clinician may also help arrange additional medications or equipment required to support the recipient for the duration of the wish.

Requesting a final wish earlier – rather than waiting until the last days of life – offers important benefits. Early referrals allow time for careful planning, clinical review, and coordination of volunteers, transport, and equipment, increasing the likelihood that the wish can be fulfilled safely and as intended. Earlier wishes are also often more comfortable and meaningful for recipients, who may have greater energy, awareness, and ability to participate. Families also benefit from reduced stress and the opportunity to share unhurried, meaningful moments together. An early wish helps create lasting memories – when they can be most fully experienced.

To request a wish please complete the below form to the best of your knowledge. On successful submission of the online form, you should receive an email copy of the submitted form.

YOUR DETAILS

Your name

First

Last

Phone

Relationship to Wish Recipient

If applying for yourself, please leave blank.

Who should Ambulance Wish Western Australia contact regarding the final wish?

You/ Your organisation (Ward/ Facility may be contacted for requests from staff)
Wish Recipient
Both

Preferred method of contact

Email
Phone

WISH RECIPIENT DETAILS

Recipient name

First

Last

Preferred name (if different)

Date of Birth

Phone

Email address:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary diagnosis

If the wish recipient is currently receiving care in a medical facility, please specify which hospital/hospice and ward.

Is the wish recipient receiving oxygen therapy?

Wish recipient weight

Less than 100 Kg
100 Kg to 120 Kg
121 Kg to 150Kg
More than 150 Kg

LEAD CLINICIAN (DOCTOR IN CHARGE OF CARE) DETAILS

Clinician name

First

Last

Phone

ELIGIBILITY

Wish recipient diagnosed with a life-limiting condition and/or a prognosis of less than 12 months

Yes
No
Unsure

Wish recipient requires specialised transport to visit their place of personal significiance due to logistical/ transport barriers or medical needs?

Yes
No
Unsure

Does the recipient have the approval of their lead clinician to undertake this journey?

Yes
No
Unsure

Does the recipient have an Advanced Health Directive (AHD)/ Advance Care Plan/ Values & Preferences Form or similar?

Yes
No
Unsure

Is there an Enduring Power of Guardianship / Guardianship Order in place for the wish recipient?

Yes
No
Unsure

Has the Wish Recipient been approved under the WA VAD Act 2019?

Yes
No
Unsure

Each wish is individually assessed. Responses to the above questions will not affect consideration.

FINAL WISH REQUEST

Desired location

Please provide us with some details of the final wish and its significance.

Do you have a preferred date or time for fulfilment of the wish?

Date

Time

Either type your date or click on the calendar. We do our very best to accommodate all requests, however, short notice wishes can sometimes be challenging to fulfil due to volunteer availability.

Are there any assistance animals accompanying the wish recipient?

Are there any pets/ animals at the wish location?

ADDITIONAL INFORMATION

Has a wish been previously requested for this person?

Do you grant Ambulance Wish Western Australia permission to use images and/ or video recorded during the Final Wish to document the wish and promote Ambulance Wish Western Australia?

Yes
With approval
No

Wish recipients, or their authorised representatives, will be asked to sign an image consent form as part of the wish request process and Ambulance Wish Western Australia's Image consent policy.

FINAL WISHES

* Ambulance Wish Western Australia is volunteer run and all journeys are subject to the availability of volunteers.

*A family member of carer can accompany the Wish Recipient in the Wish Ambulance.

*The Wish Recipient must be able to consent to the Final Wish.

*The Final Wish request is not confirmed until you receive a phone call and/ or email.

Yes, I agree to the wish conditions.

By filling in this form you give Ambulance Wish Western Australia permission to use your personal data for the realisation of the final wish. This data will be kept securely in the archives of Ambulance Wish Western Australia for seven years.