Family & Friends course enquiry form

First Name *

Surname *

Contact Email *

Which course or workshop are you interested in attending? *

January 20Febuary 21

Name of the person with dementia *

Your relationship to the person with dementia *

Do they live alone, with family, in care, live-in carers? *

live alonewith familyin carelive in care

What is the structure of the close family? *

Has the person had an official diagnosis? *

YesNo

If diagnosed, when?

When did you first notice there was a problem? *

What concerns you most about your person with dementia? *

Have you read Oliver James’ book? *

YesNo

Have you seen/downloaded our brochure? *

YesNo