People with Lived Experience

First Name *

Last Name *

Are you primarily

Living with a diagnosis of rare or young onset dementia

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

At risk of developing a rare or young onset dementia

Worried about or seeking diagnosis for symptoms of rare or young onset 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

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

What rare or young onset 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)

All of the above diagnosis

Other

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)

Your Email Address *

Enter Email

Confirm Your Email Address *

Confirm Email

Password *

Create Password

Confirm Password *

Confirm Password

Your Contact Telephone Number

Alternative Contact Telephone Number

Your Province

Your Postal Code

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?

Is this practitioner helping you with this referral?

Yes

Member Consent

I understand that Rare Dementia Support Canada is collecting and holding information about me in order 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 or young onset dementia; and research opportunities. I understand that I may receive a phone call from Rare Dementia Support Canada. I know that I can unsubscribe at any time.

CAPTCHA

If you are human, leave this field blank.

Thank you for your interest in becoming a member of Rare Dementia Support Canada!

Community