Courter Memory Center Interest Form

Courter Memory Center Interest Form

Please complete the following form if you have any interest in having a loved one attend our Center. This will take around 5 minutes. We appreciate your time in taking this!

Name
Name
Name of loved one needing assistance
Name of loved one needing assistance
Gender Identity
Does the person needing care have a dementia related diagnosis? If yes, when was it given
Does the person needing care have any other medical conditions? If yes, please briefly describe
What level of assistance is needed in the bathroom?
What level of assistance is needed with meals?
Please select the days and times you are most interested in attending (Please understand that this is only a request, not a guarantee. Scheduling will be discussed in more detail at your in-person consultation)
How did you hear about the Memory Center? (select all that apply)

We would like to thank you for taking the time to complete this survey. It will help us better serve you in the future.

Should you want more information, please call us at 269-585-7790 or email us any questions at cmcinfo@comstockcc.com