Please note that this web site may be unavailable between 10:00 PM and 02:00 AM Central time. If you are in the process of entering information, be aware that your session could be interrupted at any time. We apologize for any inconvenience this may cause.
Early-Stage Series
Referral Form for
Western Carolina Chapter
Early Stage Program
The Western Carolina Chapter, Early-Stage Program offers a fun and comfortable way for people living in the early-stages of the disease to get out, get active and get connected with one another through a variety of social events and support services. If you or a loved one is interested in participating, please fill out the information below.
Person Making Referral: ____________________________ Title: ______________________________
Organization:__________________________________________________________________________
Phone: _____________________________________ Email: ___________________________________
Person with Dementia
Name: _______________________________________________________________________________
Best Number to Call: ___________________________________________________________________
Best Time to Call (insert preferred times below indicating am or pm)
|
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
|
|
|
|
|
|
Is it OK to leave a message if no one is home? YES NO
I would like more information about the Alzheimer’s Association Western Carolina Chapter Early-Stage Program.
Signature: __________________________________________________ Date: _____________________
Person with Dementia
Please forward this referral form to Ashley Stevens, MSW
Fax: 704-532-5421 | Astevens@alz.org