Person with Dementia - Alzheimer Society of Toronto

PLEASE NOTE: This program is for people living with dementia and/or caregivers who reside in Toronto (‘M’ area code)
Date:
Person with Dementia:
Caregiver / Contact Person:
Name:
Name:
_
Date of Birth:
Relationship to person with dementia:
_
Diagnosis:
Preferred Language:
_
Preferred Language:
Phone Number: ________________________________
Email Address: ________________________________
Person with dementia resides:
Alone
With a caregiver
In a residential facility
Phone Number: _________________________________
Email Address: __________________________________
Mailing Address:
Please Contact:
Person with Dementia
Caregiver / Contact Person
Preferred method of contact:
To be contacted:
Phone
Both
Email
As soon as possible
Other:
____________________
The contact person has given consent to be contacted by the Alzheimer Society of Toronto:
Is it okay if we leave a voice message:
Yes
Yes
No
No
Caregiving Situation – Please ask client to respond
1) On a scale of 0 to 10, how stressed do you feel regarding your caregiving role?
0
1
2
3
Not at all stressed
4
5
6
7
8
Somewhat stressed
9
10
Extremely stressed
2) Do you feel that you have enough people in your life that you can ask for help at any time?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
Neutral
Agree
Strongly Agree
3) Do you feel connected to your family, friends and acquaintances?
Strongly Disagree
Disagree
4) Do you feel isolated from others?
Strongly Disagree
Disagree
5) Do you feel burdened because of the cost involved in your caregiving duties?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
6) How often do you participate in activities (other than caregiving) that are enjoyable or meaningful to you?
At least once a day
At least once a week
At least once a month
At least once a year
Never
Good
Very Good
Excellent
7) In general would you say your health is:
Poor
Fair
SG®
Services Required:
Support Group
Information Package
Services in the Community (ie. ADP)
Counselling
iPod Project
Education
MedicAlert Safely Home
Caregiver Project
Other:___________________________________________________________________________________________
Additional Information:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Referral Source Information:
Name: ______________________________________ Title/Position: ______________________________________
Organization: ____________________________________________________________________________________
Phone: ______________________________________ Fax: ________________________________________
E-mail: ______________________________________
Follow-up Preference:
Fax
Email
None Required
For more information about referring a client/patient please contact:
Laura Garcia, First Link Coordinator
Alzheimer Society of Toronto
416-640-6309 | [email protected]
FOR INTERNAL USE ONLY
Completed By:
Explained and offered AST services
Contact / Attempts:
Information package was sent to client
/
/
at
/
/
at
/
/
at
Client prefers to contact AST as needed
Counsellor was unable to reach client
Client was referred to local chapter
Counsellor will call client again (specify when)
Counsellor will meet with client
Other:
_____
______________
__________________________________
Comments: