Participant form | thedotcollective

A MAP TO YOU - FAMILY PARTICIPANT QUESTIONNAIRE

Thank you for being a part of A Map to You. It’s all about us getting to know you and your family member and creating a story based on your life experience, memories and interests. To help us get to know you a bit better before we meet, please have a look at the questions below.

Full Names (please list yours and your family members)

Phone

Address (of meeting place)

THIS SECTION IS TO BE ANSWERED ABOUT THE PERSON LIVING WITH DEMENTIA

1. HAVE THERE BEEN ANY CHANGES TO YOUR NAME OVER THE YEARS? (e.g. marriage, work, nicknames, abbreviations)

2. WHERE ARE YOU FROM? (list any places that are relevant, including Birthplace and places of residence)

3. OCCUPATION (Can be more than one job, or bringing up children etc)

4. HOBBIES - Do you have any specific interests or hobbies?

5. PLEASE TELL US ABOUT YOUR FAMILY (e.g partners, children, grandchildren, parents)

6. WHAT’S YOUR FAVOURITE MUSIC?

7. IS THERE ANY OTHER INFORMATION THAT WILL HELP US KNOW YOU BETTER?

Thank you for this information. Please also tell us below about any specific needs relating to the dementia that we need to be aware of. we are experienced in working with those with dementia but also aware that everyone is different and want to make sure we are completely sensitive to your needs.

Thanks for submitting!