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Which race category best describes you?

What is your age?

What is your gender identity?

How did you find out about Rare Dementia Support Canada?

Which of the following best describes you?

Person affected by rare dementia (living with, caring for a person affected by or interested in rare dementia)

Practitioner

Are you primarily

Living with a diagnosis of rare dementia

Caring for someone with a diagnosis of rare dementia (e.g., spouse/partner, child, sibling, other family member or friend)

At risk of developing a rare dementia

Worried about or seeking diagnosis for symptoms of rare dementia

What primary diagnosis of rare or young onset dementia do you or the person you are caring for have?

Young onset Alzheimer’s disease (YOAD)

Frontotemporal dementia (FTD) including behavioural variant FTD (bvFTD)

Primary progressive aphasia (PPA) including progressive nonfluent aphasia (PNFA), semantic dementia (SD) and logogenic aphasia (LPA)

Lewy Body dementia (LBD)

Posterior cortical atrophy (PCA)

Familial Alzheimer’s disease (FAD)

Familial frontotemporal dementia (fFTD)

Other; please identify variantOther; please identify variant

Is there a secondary diagnosis?

Young onset Alzheimer’s disease (YOAD)

Frontotemporal dementia (FTD) including behavioural variant FTD (bvFTD)

Primary progressive aphasia (PPA) including progressive nonfluent aphasia (PNFA), semantic dementia (SD) and logogenic aphasia (LPA)

Lewy Body dementia (LBD)

Posterior cortical atrophy (PCA)

Familial Alzheimer’s disease (FAD)

Familial frontotemporal dementia (fFTD)

Other; please identify variantOther; please identify variant

What can we offer you?

Direct support services for individuals and/or families

Resources, information and training on emerging evidence-informed practice

Opportunities to contribute to new learning and co-produce activities (i.e., awareness and advocacy initiatives, service evaluation and development, research)

(Please select all that apply)

Is a practitioner helping you with this referral?

Yes

What rare dementia is most relevant to you?

Young onset Alzheimer’s disease (YOAD)

Frontotemporal dementia (FTD) including behavioural variant FTD (bvFTD)

Primary progressive aphasia (PPA) including progressive nonfluent aphasia (PNFA), semantic dementia (SD) and logogenic aphasia (LPA)

Lewy Body dementia (LBD)

Posterior cortical atrophy (PCA)

Familial Alzheimer’s disease (FAD)

Familial frontotemporal dementia (fFTD)

Other; please identify variantOther; please identify variant

What can we offer you as a practitioner member?

Direct support services for individuals and/or families you work with

Resources, information and training on emerging evidence-informed practice

Opportunities to contribute to new learning and co-produce activities (i.e., awareness and advocacy initiatives, service evaluation and development, research)

(Please select all that apply)

What is your role as a practitioner?

Please choose the description that best matches your role

I am registered with a regulatory body

Yes

What type of organization do you work for?

What is the name of the organization?

Member Consent

I understand that RDS Canada is collecting and holding information about me to provide support, information and resources to me, and to develop the service. I understand that I will receive information via email on support group meetings and activities; learning materials, resources and news on rare dementia; and research opportunities. I understand that I may receive a phone call from RDS Canada. I know that I can unsubscribe at any time.

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