Dementia Self-Management Program Interest Form Dementia Self-Management Program The Dementia Self-Management Program The Dementia Self-Management Program is designed for people living with mild to moderate dementia or cognitive changes. Participants must either have a diagnosis of a dementia-related condition or have concerns that the cognitive changes they are experiencing might be dementia-related, in which case a comprehensive cognitive assessment from a qualified provider is strongly encouraged, but not required, before program participation. This particular offering of the Dementia Self-Management Program is not for family members or friends who provide support and/or care to a loved one living with dementia. While support partners are welcome to wait onsite during the program, they will not be allowed into the same room as program participants. As such, the person living with dementia must be able to participate in the program independently. The facilitators are not authorized to provide any assistance beyond normal program facilitation. Please note, participation in the Dementia Self-Management Program requires some reading and writing. If a person is experiencing difficulty with the written or spoken word, then this program may not be a good option. Dementia Friendly Nevada offers another twice-weekly program opportunity, Dementia Conversations, that is focused on living well with dementia and does not require any reading or writing. Dementia Conversations is offered online, on Monday mornings and Friday afternoons, and is open to both people living with dementia and support partners. Please visit www.dfnv.org/dementia-conversations for more information about this alternative program. If you have questions about which program might best support your participation, please contact the Dementia Engagement, Education, and Research (DEER) Program at firstname.lastname@example.org or call 775-682-9444. The DEER Program wants all participants to experience comfort, enjoyment, and success in their chosen program(s). Please answer the following questions so we can get you enrolled in a future session of the workshop. Are you completing this registration for yourself, or on behalf of someone else who is living with dementia?(Required) Myself Someone else What is your name?(Required) First Last What is the name of the person living with dementia who would be participating?(Required) First Last What is the best phone number for us to reach you at?(Required)What is the best email address for us to reach you at? What day(s) of the week would you prefer this program to be held? Check all days that work for you. Mondays Tuesdays Wednesdays Thursdays Fridays What time of day works best for you, generally? Check all times that work for you. Mornings (8-11am) Early afternoon (12-3pm) Early evening (4-6pm) Would you prefer to participate in this weekly program online (via Zoom) or in-person?(Required) Online (via Zoom) In-Person (in Reno) Either online or in-person. Use this space to tell us if there is anything else we should know.