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Please answer the questions below to register to attend the Memory Care Support Group. We will be in contact if we need additional information, and with reminders about the upcoming Memory Care Support Group meetings.

* Name of individual with memory loss:
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* Date of Birth:
0/50
* Address:
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* 1. Has the person you are caring for been diagnosed with a form of dementia?
If you answered "Yes" to question 1, what was the diagnosis and when was it made?
0/500
* 2. Has the person been told of this diagnosis and what it means?
* 3. What are some of the symptoms you have been noticing recently? Specifically, has the individual experienced changes in mood or behavior such as agitation, problems following a conversation, problems with speech or comprehension, lack of interest in social situations, inability to sit, stay focused, and interested in a group for 90 minutes?
0/500
* 4. Does the person talk about the diagnosis or his/her symptoms or changes often?
If yes, what is the nature of those discussions? How does the person respond when you talk about the diagnosis?
0/500
* 5. Who will be accompanying the person to group meetings?
0/500
* Does the person face any problems with mobility or other health issues that could affect attendance?
0/500
* Your Name:
0/250
* Your Email Address:
0/250
Your Phone Number:
0/250