Memory Coaching & Strengthening Intake
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Concerns & Goals
For memory coaching & strengthening
1. Cognitive concerns (check all that apply)
Rows
Yes
Details of Condition
Forgetting names or recent conversations
Difficulty following instructions
Misplacing items frequently
Repeating questions or stories
Getting lost or disoriented
Changes in focus or attention
Trouble completing familiar tasks
2. Current supports in use:
*
Medication for memory or cognition
Memory aids (calendar, notes, apps)
Structured daily routine
Cognitive therapy or brain games
None
Please describe any memory strategies currently used:
3. Goals for memory coaching (check top priorities)
Rows
Yes
Notes (optional)
Improve memory for names and events
Enhance attention and concentration
Support independence with daily tasks
Increase confidence with communication
Reduce frustration or anxiety
Encourage social interation
Provide caregiver education/support
4. Personal interests & background: please list hobbies, previous career, or topics they enjoy discussing.
5. What time of day is best for focus and participation?
*
Morning
Midday
Afternoon
Variable
6. Family involvement: Would you like to receive progress updates or participate in sessions?
*
Yes, regularly
Occasionally
No, thank you
7. Preferred contact method
*
Phone
Email
In-person
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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