Early Stage Cognitive and Social Engagement Program || Alzheimer's Association MI
Please reach out to info@createcircles.org or kridavis@alz.org if you have any questions at all. We are here to help in any way that we can.
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Email *
Name *
Address *
City, State, Zip Code *
Phone Number *
Referred By
Does the PWD (person with dementia) have a diagnosis of early-stage Alzheimer's, other dementia, or MCI? *
Is the PWD able to participate in (give and take) dialogue and express him or herself? *
Does PWD demonstrate a clear understanding of the questions being asked of him/her? *
Does the PWD express interest in participating in social activities with others living with Alzheimer's or other dementia?
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Gender *
Reside in long-term care community? *
If yes, which one?
This information allows us to better communicate.
Which languages do you speak? (our volunteers know over 20 different languages) *
Required
What interests do you have?
Anything from hobbies to past occupations and everything in between!
What is the chat platform of choice? *
Required
Include any numbers/usernames/etc for the chat platforms. *
Note: If you are filling this form out for multiple people, please pay attention to the time slots and number of devices that may be used at a certain time.
How often would you like to speak with a volunteer? *
Time Preference for Visit *
Visits will be 30 minutes - 1 hour.
Required
Name of Point of Contact or Emergency Contact *
This section is to be filled out by the point of contact. It may be the older adult themselves or someone at the long-term care facility. This person will receive all information about the visits and will be responsible for assisting us to make the visit possible.
Email of Point of Contact or Emergency Contact *
Phone Number of Point of Contact or Emergency Contact *
A copy of your responses will be emailed to the address you provided.
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