Active Memory Coach
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Household Basics
Caregiver first name
*
Person receiving Care first name
*
Relationship to the person receiving care
*
Spouse / partner
Adult child
Other family member
Friend
Paid caregive
Other
Please describe your relationship
*
Where does the person you care for usually live?
*
Lives with me
Lives alone, with support
Lives with another family member
Assisted living / care community
Other
Other living situation
Which best describes the current care situation?
*
Mostly independent, but needs reminders
Needs help with several daily routines
Needs supervision much of the day
Needs hands-on help with many activities
Needs changes day to day
Which tone should the manual use?
Warm and encouraging
Direct and practical
Gentle and calming
Balanced: practical but supportive
If you are human, leave this field blank.
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