So Me Agency on Aging
Adult Day Program - Request More Information
Thank you for your interest in the Adult Day Program at the Sam L. Cohen Center, Southern Maine Agency on Aging.
Your Name:
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First
Last
Organization/Company name if a service provider
What is your relationship to the potential Adult Day Program member?
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Family member
Patient
Other
If other, please let us know in what capacity you refer the client to us:
Preferred contact method (check all that apply):
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Phone
Email
Phone number:
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####
Is it ok to leave a message at this phone number?
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Yes
No
Email:
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Best time to reach you (check all that apply):
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Early Morning 8am-10am
Late Morning 10am-12pm
Early Afternoon 12pm-2pm
Late Afternoon 2pm-4pm
Other
If other, please indicate which time is best for us to reach you:
How did you learn about the Adult Day Program? Please check all the apply.
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Doctor or Geriatrician
Television
Radio
Newspaper
Community Fair/In-person event
SMAA newsletter
SMAAA.org website
Open House
SMAA Employee
Word of Mouth (A friend, family member, or other caregiver)
SMAA Class or Support Group
Another Agency (VA, Alzheimer's Association, etc.)
Drove By / Location
Other
If other, please let us know where or how you heard about the Adult Day Program:
If SMAA Class or Support Group, please, tells us which service or program:
Family Caregiver Classes (Savvy Caregiver, Support Groups, Understanding Cognitive Loss workshop)
Agewell Classes (Tai Chi, A Matter of Balance, Falls Prevention, etc.)
Medicare class or 1:1 assistance
Reasons for your inquiry
*
General information/Assistance
Request a tour
Request a trial visit
About your Request
Please let us know if you have any specific questions, or if there is any information we should know before responding.
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