Intake Form for Family Coaching

Please provide the following information regarding the person diagnosed with Alzheimer's or a related dementia, as well as other information needed for your coaching session. Be sure to enter "n/a" in any field that does not apply.

Upon receipt of your completed form, we will email you with a range of meetings days and times for your session.

1) *Your Full Name:
2) *Your Email Address:

3) *Relationship to Person Diagnosed:
4) Type of Coaching You're Requesting:

5) Which role do you occupy with the Person Diagnosed?

6) *Your Complete Address:

7a) *Best Telephone # for Reaching You:
7b) This # is your:

8) *Full Name of Person Diagnosed:

9) *Age of Person Diagnosed:

10) *Complete Address of Person Diagnosed:

11a) *What issue(s) would you like addressed in the session? (Select all that apply)
In-Home ActivitiesSafety IssuesEducation About the DiseaseOut-of-Home PlacementCommunication IssuesHome Care OptionsOther
11b) If you selected "Other", describe the issue here:

12) Preferred Day for the Session:

13) Preferred Start Time for the Session:

14) Expected No. of Attendees in Your Party (including you):
15) *Name of Referring Person and/or Organization:

16a) *Name of Person to Receive Invoice:
16b) *Email Address of Person to Receive Invoice:
17) *I Prefer to Pay My Invoice by (choose one):
CheckCredit Card
18) In submitting this form, I (person listed in # 1) confirm that I have power of attorney or am otherwise authorized to order services from Engaging Alzheimer’s LLC for the diagnosed person listed in # 8 (The Client) of this Intake Form.

I further acknowledge that I and the person listed in # 16a of this Intake Form assume full responsibility for all bills arising from this request for services and agree to pay said bills as rendered within 15 days of issuance, unless a bill(s) is in dispute. I agree to notify Engaging Alzheimer’s LLC of any dispute, in writing, within 15 days of the date of the applicable bill/invoice.

I Agree