Brain Health & Respite Program Inquiry

Question Title

* 1. Please provide your contact name.

Question Title

* 2. Please provide the name of the person interested in enrolling in the Brain Health & Respite Program (hereafter referred to as Participant).

Question Title

* 3. What is your relationship to the Participant?

Self

Spouse

Child

Care Partner

Other (please specify)

Question Title

* 4. Please provide your contact email.

Question Title

* 5. Please provide your contact phone number.

Question Title

* 6. What is the age of the Participant?

under 50 years

50-65 years

65-80 years

over 80 years

Question Title

* 7. Which program(s) are you interested in enrolling the Participant?

Tuesdays: 9:30am-2:30 pm at Saint Andrews Presbyterian Church, 4882 Lavista Road, Tucker, GA 30084

Wednesdays: 9:30am - 2:30pm at Gwinnett County Resource Center at Bethany Road, 3025 Bethany Church Road, Snellville, GA 30039

Question Title

* 8. Does the Participant have a diagnosis of Alzheimer's of dementia or other neurocognitive disorder?

Yes

No, but suspected

No, but has other cognitive decline (e.g. short term memory loss, etc.)

No, is just interested in socialization and activities

No, but has a history of traumatic brain injury (e.g. stroke, accident, etc.)

Other (please specify)

Question Title

* 9. Is the participant able to stand, walk, feed, and bathroom himself/herself independently (with or without an assistive device)?

Yes

Question Title

* 10. What do you and the Participant hope to gain from enrolling in the program?

Question Title

* 11. What is the best way to contact you?

Phone

Question Title

* 12. Please specify best day and time to contact you.

Monday

Tuesday

Wednesday

Thursday

Friday

Best Time (please specify)

Question Title

* 13. How did you hear about us?

Social media

Friend or family

Online search

Advertisement/Flyer

Other (please specify)