ECI Music & Memory Assessment Questionnaire

ECI Music and Memory Assessment Questionnaire

Caregiver Name*
First Last
Caregiver's Phone*
Caregiver's Email*
Music Listener's Name*
First Last
Age*
Diagnosis*
Do you have a favorite type of music? (Big Band, Jazz, Rock, R&B, Country, Easy Listening, Classical, Instrumental, etc.)*
Which artists did you listen to in your teens and 20’s?*
Who was your favorite singer, group, band?*
Do you have any questions or concerns?
FAVORITE ARTISTS and SONGS for PERSONAL PLAYLIST __ (Please list 12-15 favorite artists and songs to help comprise a personal playlist)*
Please read and acknowledge the following:
MUSIC & MEMORY PARTICIPATION CONSENT: I hereby give my consent to either personally participate in The Edel Caregiver Institute (ECI) Music & Memory program or as an authorized family caregiver give my consent for care recipient noted in above questionnaire to participate in the program. I understand the music listener or authorized family caregiver may withdraw from the program at any time by contacting the Edel Caregiver Institute (912.629.1331) and speaking with the Music & Memory coordinator. As well, all equipment utilized is the property of the Edel Caregiver Institute. Please include your name and the date in the box below to denote agreement and signature.
MUSIC & MEMORY MEDIA RELEASE (not requirement for participation in program): I authorize Hospice Savannah, Inc. and its affiliates to record, photograph, and interview me for public viewing, educational purposes, and promotional materials. I understand and agree that these recordings and images may be used on their website and for promoting Hospice Savannah’s services. I acknowledge that I can withdraw this consent before any use of the recordings, films, or photographs. Please include your name and the date in the box below to denote agreement and signature.
Name
This field is for validation purposes and should be left unchanged.

ECI Music & Memory Assessment Questionnaire

ECI Music and Memory Assessment Questionnaire

Please read and acknowledge the following: