Courter Memory Center Interest Form

Courter Memory Center Interest Form

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

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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)