DementiaCoach® Private Classes (CO) – Initial Survey

Before we get started, we need to know a few things about your care situation. We’d also like to know how you and your loved one or client are feeling currently. Please take a little time to fill out our pre-class survey. Your answers will help us match you with a DAWN Trainer and help that trainer to prepare.

DementiaCoach Private Classes – Initial Survey (CO)

We recommend that the person who spends the most time with your loved one who is experiencing dementia fill out this form.

Name(Required)

First Last

Email(Required)

How did you find out about the DementiaCoach classes for families?(Required)

What is your relationship with the person experiencing dementia (i.e. daughter, son, friend, spouse, partner)?

Do you live with them?

Yes

Do they live alone?

Yes

Are they able to understand (or accept) that they are losing skills and/or need help?

How much time, on average, does the person experiencing dementia spend with you or other people?

(hours/day, hours/week)

Wellbeing Assessment

How would you describe your family culture? (primarily the relationships between parents and children)(Required)

How would you describe your experience as a caregiver up to this point?

How would you describe the emotional state of the person experiencing dementia?

What is your greatest concern about providing dementia care?

Thank you for your time! Dementia & Alzheimer’s Wellbeing Network® The DAWN Method®

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