Dementia Support Care Plan Form
Use this form to outline support needs, routines, safety considerations, and key contact details for a person living with dementia.
Care Recipient Information
Care recipient full name
*
First Name
Middle Name
Last Name
Date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Dementia diagnosis/status
Please Select
No diagnosis
Mild cognitive impairment
Early-stage dementia
Moderate-stage dementia
Advanced-stage dementia
Not sure
Other
Current living arrangement
*
Please Select
Lives alone
Lives with spouse/partner
Lives with family member
Assisted living
Memory care facility
Skilled nursing facility
Other
Primary language
Please Select
English
Spanish
French
Mandarin
Cantonese
Arabic
Hindi
Other
Preferred communication method
Best contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver and Contact Details
Primary Caregiver Name
*
First Name
Middle Name
Last Name
Relationship to Care Recipient
*
Please Select
Spouse
Child
Parent
Sibling
Other Relative
Friend
Professional Caregiver
Other
Primary Caregiver Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Caregiver Email
example@example.com
Emergency Contact Name and Phone Number
*
Daily Care Needs and Support
Daily support needs
*
Bathing
Dressing
Toileting
Grooming
Meal preparation
Feeding support
Medication reminders/assistance
Transportation
Housekeeping
Supervision
Supervision level
*
Please Select
Independent
Periodic check-ins
Intermittent assistance
Frequent assistance
Continuous supervision
Other
How often is support needed?
*
Several times a day
Daily
A few times a week
Weekly
As needed
Other
Describe the amount and timing of support needed
Health, Safety, and Behavior
Mobility Status
*
Independent
Uses cane or walker
Requires physical assistance
Wheelchair user
Bedbound
Other
Current Safety and Behavior Concerns
*
Fall risk
Wandering risk
Confusion
Agitation
Sleep concerns
Appetite or nutrition concerns
Other
Behavioral Symptoms or Incidents
Triggers for Confusion or Agitation
Strategies That Help Calm or Redirect
Notable Safety Precautions
Routines, Preferences, and Care Instructions
Preferred daily routine
Preferred activities
Communication approach that works best
Dislikes or triggers to avoid
Additional care instructions or notes
Submit Care Plan
Should be Empty: