Ceresti partners with caregivers and families to improve the experience of
living with Alzheimer’s Disease and other dementias, at home. The Ceresti
Cognitive Health Program is a first-of-a-kind, specialized, at-home dementia
care service that aims to reduce caregiver burden and improve patient quality of
life. Our trained Care Navigators provide education, support and guidance, and
help families implement personalized action plans to achieve specific program
goals. We develop Digital Therapies to improve patient mood while reducing
negative behaviors. Our program is accessible and affordable through the use of
technology.
Ceresti is recruiting a limited number of qualified families to join our
Founding Families Program and gain access to the Ceresti Cognitive Health
Program at no charge. Founding Families will help us evaluate and optimize
our specialized, at-home dementia care service. You can play a meaningful role
in establishing a new standard of care for Alzheimer’s Disease and other
dementias.
We thank you for your interest in the Founding Families Program. Please
complete the attached application and questionnaire. Upon receiving your
completed application and questionnaire, you will be emailed an online
assessment. Our questionnaire and assessment are used to personalize this
program for you so we cannot stress enough that there are no wrong answers.
You can return these documents by mail, email, or fax.
Due to limited availability, if you are not selected for the Founding
Families Program we will place you on a waitlist. In the event a family drops out
of the Founding Families Program, you will have an opportunity to join.
Families on the waitlist will receive a discount from the retail price when the
program is offered commercially, and will receive periodic samples of the
Ceresti Cognitive Health Program. If you have any questions please contact:
Nicole McPherson
Care Navigator | Ceresti Health
2888 Loker Ave E, Ste 209 Carlsbad, CA 92010
P: (760) 453-0999 F: (760) 517-1723
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Founding Families Program Application
Family Caregiver Information
Name: _____________________________________ Date: ________________
Date of birth: __________________________
Street Address: ___________________________________________________________
City: _________________________ State: ___________
Zip Code: ___________
Primary Phone: (_____)___________________ ☐ Cell ☐ Home ☐ Work
Secondary Phone: (_____)___________________ ☐ Cell ☐ Home ☐ Work
Email Address: _______________________________________
Is the primary caregiver fluent in the English language? ☐ Yes
☐ No
Relationship to patient: ☐ Husband ☐ Wife ☐ Son ☐ Daughter ☐ Other: __________________
Does the primary caregiver live with the patient? ☐ Yes
☐ No
Does the primary caregiver use any of the following? ☐ cane ☐ walker ☐ wheelchair ☐ none
Who else plays an active role in the care of your loved one?
Name:
Relationship:
Location:
Willing to Participate?
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
How comfortable would the primary caregiver be with using a tablet device similar to an iPad?
☐ Not comfortable
☐ Somewhat comfortable
☐ Very comfortable
☐ What is a tablet or iPad?
☐ I am eager to learn how to use a tablet or iPad!
Patient Information
Name: ____________________________ Date of Birth: ________________ Age: __________
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Marital Status: ☐ Married
☐ Divorced
Ethnicity: ______________________
☐ Widowed
☐ Single
Language(s) Spoken: _________________________
Is the patient fluent in the English language? ☐ Yes
☐ No
Diagnosis:
☐ Alzheimer’s Disease
☐ Frontal Temporal Dementia
☐ Mixed Dementia
Stage:
☐ Mild
☐ Dementia
☐ Vascular Dementia
☐ No formal diagnosis
☐ Moderate
☐ Mild Cognitive Impairment (MCI)
☐ Lewy Body Dementia
☐ Severe
Secondary Diagnoses/Comorbidities: (please check all that apply)
☐
☐
☐
☐
☐
Arthritis
COPD
Frequent UTIs
Macular Deg.
Stroke
☐
☐
☐
☐
☐
Atrial Fibrillation
☐ Cancer
Coumadin Therapy ☐ Diabetes type 1
Hypertension
☐ Hypothyroidism
Osteoporosis
☐ Parkinson’s Disease
Other diagnoses: (please specify below)
☐
☐
☐
☐
CHF
Diabetes type 2
IBS
Pressure Ulcers
☐
☐
☐
☐
Kidney Disease
Frequent Falls
Insomnia
Sleep Apnea
__________________________________________________________________________________________
__________________________________________________________________________________________
Insurance Provider: ________________________ Secondary Insurance: ________________________
Long Term Care Insurance: ☐ Yes
☐ No
Provider: ______________________________
Are you willing to give Ceresti Health access to relevant medical information? ☐ Yes
☐ No
Does your loved one experience or display any of the following: (please check all that apply)
☐ Agitation
☐ Inappropriate Behaviors
☐ Aggressive Behaviors
☐ Long-term memory
loss
☐ Short-term memory loss ☐ Sun downing
☐ Depression
☐ Paranoia
☐ Hallucinations
☐ Short Attention
Span
☐
Wandering
On a typical day, the patient requires the following level of assistance with daily activities such
as walking, dressing, toileting, or showering.
☐ Minimum Assistance
☐ Moderate Assistance
☐ Maximum Assistance
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☐ Total Care
Additional Information
1. What is your IDEAL care plan for your loved one?
☐ Stay at home
☐ Bring in home care
☐ Move into a memory care facility
☐ Move into an assisted living home
2. Is your loved one currently living in any of the following?
☐ Independent Living
☐ Assisted Living
☐ Memory Care
☐ Skilled Nursing
3. Is professional help being brought into the home to provide care? ☐ Yes
☐ No
If so, which agency? ____________________________________________________________
4. How would you rate your family’s involvement in your loved ones care?
☐ Not involved
☐ Somewhat involved
☐ Very involved
5. Is the patient/primary caregiver currently participating in a research study? ☐ Yes No
If so, which study? _____________________________________________________________
6. How did you learn about the Founding Families Program?
☐ Internet search
☐ Received a flyer
☐ Attended an event or presentation
☐ Referral; who referred? ______________________________________
☐ Other:
____________________________________________________
If you have any questions please do not hesitate to contact:
Nicole McPherson
Care Navigator
Ceresti Health
2888 Loker Avenue E, Ste 209
Carlsbad, CA 92010
(760) 453-0997
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Please select the best option as it relates to you.
I perceive myself as:
I perceive myself as:
Quiet...........................................Talkative
Open...............................................Closed
☐1
☐2
☐3
☐4
☐4
☐3
☐2
☐1
Slow to Decide ..................Fast to Decide
☐1
☐2
☐3
☐4
Impulsive....................................Deliberate
☐4
☐3
☐2
☐1
Going along.......................... Taking charge
☐1
☐2
☐3
☐4
Using opinions ...........................Using facts
☐4
☐3
☐2
☐1
Supportive................................ Challenging
☐1
☐2
☐3
☐4
Informal......................................... Formal
☐4
☐3
☐2
☐1
Compliant....................................Dominant
☐1
☐2
☐3
☐4
Emotional............................... Unemotional
☐4
☐3
☐2
☐1
Deliberate.............................Fast to Decide
☐1
☐2
☐3
☐4
Easy to know.........................Hard to know
☐4
☐3
☐2
☐1
Asking questions.......Making statements Warm.................................................Cool
☐1
☐2
☐3
☐4
☐4
☐3
☐2
☐1
Cooperative............................. Competitive
☐1
☐2
☐3
☐4
Excitable............................................Calm
☐4
☐3
☐2
☐1
Avoiding risks.......................... Taking risks Animated.................................Poker-faced
☐1
☐2
☐3
☐4
☐4
☐3
☐2
☐1
Slow, studied............................. Fast-paced
☐1
☐2
☐3
☐4
People-oriented...................Task-oriented
☐4
☐3
☐2
☐1
Cautious....................................... Carefree
☐1
☐2
☐3
☐4
Spontaneous.................................Cautious
☐4
☐3
☐2
☐1
Indulgent............................................Firm
☐1
☐2
☐3
☐4
Responsive ..........................Nonresponsive
☐4
☐3
☐2
☐1
Nonassertive.................................Assertive
☐1
☐2
☐3
☐4
Humorous ......................................Serious
☐4
☐3
☐2
☐1
Mellow................................. Matter-of-fact
☐1
☐2
☐3
☐4
Impulsive...................................Methodical
☐4
☐3
☐2
☐1
Reserved......................................Outgoing
Lighthearted.................................... Intense
5
☐1
☐2
☐3
☐4
☐4
6
☐3
☐2
☐1