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First Name
Last Name
Phone
Email
Do you have a smartphone?
*
iPhone
Android
Both
Neither
What kind of internet service do you have in your home?
*
Wi-Fi
Router with open ethernet port
Both
Neither
Are you currently living with and serving as the primary caregiver for a person who has received a diagnosis of dementia or mild cognitive impairment?
*
Dementia
Mild Cognitive Impairment
Neither
I am not a caregiver
If you are a caregiver, has the person you care for received a diagnosis of dementia or mild cognitive impairment from a medical professional?
*
Dementia
Mild Cognitive Impairment
Neither
I am not a caregiver
What language is spoken most often in your home?
*
English
Spanish
Cantonese
Mandarin
Another Language
Do you have a cat or dog in your home?
*
Yes
No
I have a similar sized pet
Zip Code
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