CCACC Health 2022 Workshop Sign-Up Form

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CCACC Health Center will provide 6 workshops to our community in 2022 to improve the quality of life of patients who have diabetes, chronic pain, or dementia. Their caregivers are also welcome to join the workshop to learn self-management strategies.
All workshop participants are encouraged to complete the pre and post forms to help us do a better work.
Please select the workshops which you are interested in, and we will contact you for further steps.
To learn more, please visit https://www.ccacchealth.org/ or call 240-393-5950 or mail to hsiaoyin.chen@ccacc-dc.org

I am interested in joining the workshop(s): 我想參加的課程為: *

6/16-7/21 Building Better Caregivers (BBC) 失智症照顧者支持課程

8/18-9/22 Chronic Pain Self-Management Program (CPSMP) 慢性疼痛自我管理課程

10/13-11/17 Diabetes Self-Management Program (DSMP) 糖尿病慢性疾病自我管理課程

Required

First Name 名字 *

Last Name 姓氏 *

Sex 性別

Male

Female

Clear selection

Date of Birth 生日

YYYY

Phone Number 電話 *

Email 聯絡電郵 *

Address 地址

What health insurance do you have? Please check all that apply: 請問您的醫療保險種類為 *

Medicare 聯邦老年人醫療保險

Medicaid or Medical Assistance 低收入戶保險

Veteran’s or VA 退伍軍人保險

No Insurance 無保險

Private 私人保險

Other:

Required

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