Intake Package(s) - Alzheimer Society of Toronto

FAX
To:
Fax
Number:
SABRINA MCCURBIN
416-322-6656
Date:
# of Pages:
Re:
From:
Fax
Number:
Phone
Number:
Comments:
including cover
ALZHEIMER SOCIETY MUSIC PROJECT: REFERRAL
FACILITY INTAKE
Client #_________
 Individual Application
 Group Application
 Pick-Up Contact: ______________________________Phone/Email:_________________________________
Completed By:
Contact Information:
Date (dd/mm/yyyy):
FACILITY/STAFF CONTACT:
Facility Name:
Facility Type:
Supervising Staff Name:
Phone:
Email:
Fax:
Address:
City:
Province:
Postal:
Country:
FAMILY CONTACT:
Last Name:
First Name:
MI:
Phone:
Alternate Phone:
Email:
Relationship to PWD:
Address:
City:
Gender:
 Male
Province:
 Female
Other Alzheimer Society Services recommended for Family:
 Counselling
 Education
 Support Group
Postal:
 Other_____________
Country:
 Refused to Respond
 Creative Therapy
 Other _______________________
Attention: Sabrina McCurbin
th
20 Eglinton Ave West, 16 Floor Toronto, M4R 1K8
PHONE: 416-640-6305 FAX: 416-322-6656
PAGE 1
Client #_________
iPOD RECIPIENT:
Last Name:
First Name:
Date of Birth:
Room Number:
MI:
 Same as Facility Information
Address:
City:
Province:
Gender:
 Male
 Female
Dementia Diagnosis:
 Alzheimer’s Disease
 Vascular Dementia
 Mixed Dementia
 Parkinson’s Disease
Postal:
Country:
 Other_____________
 Frontotemporal Dementia
 Cruetzfeld-Jacob Disease
 NPH
 Huntington’s Disease
 Refused to Respond
 Wernicke-Karsaoff Syndrome
 Unspecified Dementia
 Other- Indicate:________________
 Lewy Body Dementia
Other Relevant Conditions:
SERVICES REQUIRED FOR PARTICIPATION: (please check all that apply)
iPod Package & music load
iPod Package only –client will self manage

Dementia/caregiver related counseling

Other __________________________________
PAGE 2
CONSENT
Client _________
I, __________________________ acknowledge the Music Project provides a portable music device, headset,
and wall charger, provided to me by the Alzheimer Society Toronto. I understand although this program has
been made available to me through ______________________ (care facility), all program requests, changes or
inquiries must be directed to the Alzheimer Society Toronto.
I agree to use the equipment as directed by the Society representative, and understand that any equipment
provided to me is provided for the duration of participation in the program. In the event I am not the primary
caregiver, I authorize the supervising staff with ________________________ (care facility) to operate the
equipment, as directed by the Society representative. I agree to return provided equipment at the time of
dismissal from the program.
I understand the participation requirements of the program, and agree to follow-up by phone, email, or in
person as the Society deems necessary for research and participation needs related to the program. I agree to
provide feedback to the best of my ability via 3 or 6 month survey.
I understand I may contact Alzheimer Society Toronto in addition to the scheduled follow-ups as I deem
necessary for additional support and programming the Society may offer. I also agree to exchange any and all
information provided with Society partners and volunteers for use within the program.
I,___________________________ as an authorized representative for __________________________
,consent to his/her participation in the Project. I understand that participation in the Alzheimer Society Toronto
Music Project is voluntary and that I may withdraw at any time. I agree to release Alzheimer Society Toronto
and their employees, representatives and agents from any liability for injury, disability or financial cost
resulting from the participation in the program.
Caregiver Signature:
Date:
______________________________________________
Caregiver Name: Print
_____________________________________________
Facility Staff Signature
Attention: Sabrina McCurbin
th
20 Eglinton Ave West, 16 Floor Toronto, M4R 1K8
PHONE: 416-640-6305 FAX: 416-322-6656
PAGE 3
Client#__________
ADMINISTRATIVE:
Device Used: iPod Shuffle -Blue
Serial Number:
Date Issued:
Music Upload Completed by:
Date:
Playlist Titled: _______________________ Created On : Facility/Client Computer _________________________
AST Computer
Coordinator Signature:
_______________________________
Date:
MUSIC PREFERENCE QUESTIONNAIRE
iPOD RECIPIENT:
Last Name:
First Name:
Room #:
Completed By:
Circle one: (Staff) (Family) (Friend) Other: ___________________________________
Country of Origin: __________________________________Mother Tongue: ___________________________________
Musical History: (choir, instrument skills, etc)
_______________________________________________________________________________________________________
How important is it to the user to listen to music he or she likes?
 Very Important
 Moderately Important
 Slightly Important
 Not Important
How does music make them feel?
__________________________________________________________________________________________________
In order to use the iPod, resident will need:
_____ No assistance
_____ Assistance with turning unit on and off
_____ Assistance putting on headphones
_____ Assistance adjusting volume
_____ Assistance recharging unit
Assistance will be available from _________________________________________ (name & title)
Attention: Sabrina McCurbin
th
20 Eglinton Ave West, 16 Floor Toronto, M4R 1K8
PHONE: 416-640-6305 FAX: 416-322-6656
PAGE 4
4
Musical Selection Possibilities (circle artists of interest)
Easy Listening
Barbra Streisand
Barry Manilow
Engelbert Humperdinck
Frank Sinatra
Les Paul & Mary Ford
Liberace
Montavani
Nat King Cole
Peggy Lee
Rosemary Clooney
The Four Lads
Tommy Dorsey
Tony Bennett
Big Bands/Swing
Benny Goodman
Eddy Duchin
Duke Ellington
Billy Eckstine
Glenn Miller
Les Brown
County Basie
Artie Shaw
Woody Herman
Country & Western
Alabama
Brad Paisly
Clint Black
Willie Nelson
Dolly Parton
Eagles
Dwight Yoakam
Garth Brooks
Kenny Rogers
Merle Haggard
Broadway
Cabaret
Camelot
Carousel
Gypsy
Sound of Music
South Pacific
Sunset Boulevard
The Music Man
West Side Story
Other Categories:
Patriotic
Eastern Europe
Instrumental
Spiritual
R&B
Andrae Crouch
Alicia Keys
Bebe & Cece Winanas
Aretha Franklin
Bishop Noel Jones
Diana Ross
Dinah Washington
Donna Summer
Donnie McClurkin
Fats Domino
Gladys Knight
Four Tops
Jackie Ball
Jackson 5
Kirk Franklin
Lionel Richie
Mahalia Jackson
Luther Vandross
Mavis Staples & Lucky Peterson
Mariah Carey
MercyMe
Marvin Gaye
Micah Stampley
Michael Jackson
Rev. James Cleveland
Otis Redding
Selah
Ray Charles
Shirley Caesar
Sam Cooke
Smokie Norful
Smokey Robinson
Wintley Phipps
Stevie Wonder
Yolanda Adams
The O'Jays
The Stylistics
The Temptations
Classical
Beethoven
Bach
Chopin
Tchaikovsky
Stravinsky
Brahms
Mozart
Andrea Bocelli
Please add any
songs, titles,
groups, types of
music:
Calypso
Klezmer
Spanish
Celia Cruz
El Gran Combo de Puerto Rico
Graciela Beltran
Jose Carreras
Juan Gabriel
Marc Anthony
Placido Domingo
Tito Rojas
Victor Manuelle
Vincente Fernandez
Rock
Beach Boys
Beatles
Bee Gees
Billy Joel
Carpenters
Elton John
Elvis Presley
Four Seasons
Four Tops
Gene Pitney
Melissa Etheridge
Neil Young
Rolling Stones
Sonny & Cher
The Byrds
The Duprees
The Eagles
The Hollies