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
Loved one's address
Loved one's address
Does your loved one need assistance with medication?

Below are questions to help us forecast interest/usage of the Wilbur and Charlotte Courter Memory Center. Your answers are not a final decision on whether your loved one attends the new Center.

Answer each question as best as you can.

About how much do you anticipate they would attend the Memory Center?
Would they require transport to the Memory Center? (if yes, we can inform you of possible transport options)

General Demographics

Loved ones information

Gender
Age
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 cmcdir@comstockcc.com