Dementia Capable Communities Toolkit
Community Needs Assessment –
Legal Counsel/Future Planning Survey
Attorneys may play a role in providing support to people with dementia and their families. Future planning is
among the key elements in a dementia capable community. Putting financial, legal and medical plans in place
as soon as the diagnosis has been made can help people secure a healthier financial future. Preparing for legal
medical provisions can reduce stress on caregivers if dementia progresses.
The information gathered here supports a portion of a full Community Needs Assessment. Each survey
question is cross-referenced to the full assessment. These questions are best investigated by someone with
experience as an attorney or an interest in law.
Assessing Future Planning for a Dementia Capable Community
1. Review the information and resources on the ACT on Alzheimer’s Dementia Capable Communities Toolkit
website related to Advance Care, Financial and Legal Planning to have a general familiarity when
discussing the topic with others.
2. Develop a list of all of the law offices in your community.
3. Prioritize and determine which organizations to contact.
4. Identify the appropriate contact(s) in these offices.
5. Keep track of your data sources, including who you interview and their responses to the questions in your
interview.
6. Create a code for each interviewee, using the sector abbreviation, plus a number. For example, legal
counsel interviewees would be LC1 for first interviewee, LC2 for second, etc. You might chose to indicate
whether the interviewee practices elder law by adding an "e,” e.g., LCe.
7. Use the Community Information Gathering - Survey/Call Script to introduce yourself and the project.
8. Conduct interviews.
9. After your information gathering, organize the data and summarize it in the Synthesizing the Assessment –
Team Worksheet, which will be the basis for how your community rates its current level of activity and
prioritizes what to focus on.
Community Needs Assessment — Legal Counsel/Future Planning Survey
www.ACTonALZ.org
©2014. This toolkit was made possible by funding from the Greater Twin Cities United Way.
Page 1 of 5
Rev. 06/05/14
Interviewer/Your Name ________________________________________Date of Interview _________
Community Member/Interviewee ________________________________Interviewee Code: LC
Name _______________________________________________________________________________
Title ________________________________________________________________________________
Address _____________________________________________________________________________
Phone ______________________________________________________________________________
Email _______________________________________________________________________________
1. Have you had personal experience with someone with dementia?
☐ Yes
☐ No
2. Have you had professional experience with someone with dementia?
☐ Yes
☐ No
☐ Yes
☐ No
Future Planning - Section E
3. Are you an elder law attorney?
4. I want to ask you about planning services that help meet the needs of people with dementia. Which of the
following planning services do you provide? (Q11 in full assessment)
Planning services that help meet the needs of people with dementia
Provide service
Traditional estate planning – including wills, trusts, etc.
☐ Yes ☐ No
Advice/counseling regarding long-term care payment options, including insurance,
private pay, government benefits, Veterans benefits, etc.
☐ Yes ☐ No
Advice/counseling regarding private and public benefits, including health insurance,
Medicare, Medicaid, etc.
☐ Yes ☐ No
Advice/counseling regarding available services and supports for institutional and
community-based care
☐ Yes ☐ No
Disability Planning – including surrogate decision-making options for finances
☐ Yes ☐ No
Disability Planning – including surrogate decision-making options for health care –
including advance directives
☐ Yes ☐ No
Other (please specify)
☐ Yes ☐ No
Community Needs Assessment — Legal Counsel/Future Planning Survey
www.ACTonALZ.org
©2014. This toolkit was made possible by funding from the Greater Twin Cities United Way.
Page 2 of 5
Rev. 06/05/14
Level of Current Activity
Priority for Action
Indicate your level of agreement with this
statement: Our community currently has an
adequate level of planning services to meet the
needs of people with dementia.
Indicate your level of agreement with this statement:
Increasing the level of planning services to meet the
needs of people with dementia should be a priority for
action in our community.
1.
2.
3.
4.
5.
0.
1.
2.
3.
4.
5.
0.
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
What opportunities do you see to make available planning services tailored to people with dementia? What
barriers do you see?
Awareness - Section B
5. This question asks you about your level of knowledge of the warning signs of dementia. (6a in
full assessment)
(10 warning signs: 1) Memory loss that disrupts daily life. 2) Challenges in planning or solving problems. 3)
Difficulty completing familiar tasks at home, at work or at leisure. 4) Confusion with time or place. 5)
Trouble understanding visual images and spatial relationships. 6) New problems with words in speaking or
writing. 7) Misplacing things and losing the ability to retrace steps. 8) Decreased or poor judgment. 9)
Withdrawal from work or social activities. 10) Changes in mood and personality)
Level of knowledge of the
warning signs of dementia
Priority for Action
Indicate your level of knowledge of the
warning signs of dementia
Indicate your level of agreement with this statement:
Increasing attorney knowledge about the warning signs
of dementia should be a priority for action in our
community.
1.
2.
3.
4.
5.
0.
1.
2.
3.
4.
5.
0.
Very low
Low
Moderate
High
Very high
Do not know
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
Community Needs Assessment — Legal Counsel/Future Planning Survey
www.ACTonALZ.org
©2014. This toolkit was made possible by funding from the Greater Twin Cities United Way.
Page 3 of 5
Rev. 06/05/14
What opportunities do you see for attorneys to know the warning signs of dementia? What barriers do you
see?
6. This question asks you about your skills for interacting with people who have dementia. (Skills for
interacting with people with dementia include knowing when to repeat information or suggesting a family
member should participate in conversations.) (6b in full assessment)
Skills for interacting with people with dementia
Priority for Action
Indicate your level of agreement with this
statement: I have good skills for interacting with
people with dementia.
Indicate your level of agreement with this statement:
Increasing attorney skills for interacting with people
with dementia should be a priority for action in our
community.
1.
2.
3.
4.
5.
0.
1.
2.
3.
4.
5.
0.
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
What opportunities do you see for attorneys to have good skills for interacting with people with dementia?
What barriers do you see?
7. If you recognize that a client may appear to have dementia—such as reduced decision-making capacity—
how would you rate your ability to make referrals to support services (such as Alzheimer’s Association,
Senior LinkAge Line, family physician) for people with dementia and their families? (Q6c in full
assessment)
Ability to make referrals to support services
Priority for Action
Indicate your ability to make referrals to
support services.
Indicate your level of agreement with this statement:
Increasing attorney ability to make referrals to support
services should be a priority for action in our
community.
1.
2.
3.
4.
5.
0.
1.
2.
3.
4.
5.
0.
Very low
Low
Moderate
High
Very high
Do not know
Strongly disagree
Disagree
Neither agree or disagree
Agree
Strongly agree
Do not know
Community Needs Assessment — Legal Counsel/Future Planning Survey
www.ACTonALZ.org
©2014. This toolkit was made possible by funding from the Greater Twin Cities United Way.
Page 4 of 5
Rev. 06/05/14
What opportunities do you see for attorneys to make referrals to support services for people with dementia
and their families? What barriers do you see?
General
Would you be interested in playing a greater role to help us implement this project in our community?
Suggestions:
 Serve on a coalition
 Serve on a task force or committee
 Public endorsement/testimonial
 Appoint a person to work on the project
 Donate resources, i.e., meeting space, advertising, personnel, funds, etc.
Could you suggest other organizations/groups in our community who could take part in
this project?
Are there any other suggestions or ideas that you can give me as we prepare to get this
project started?
Are there any questions you would like to ask me?
Thank you for your time and support.
Would you like me to be in touch with you again to let you know how the project is progressing and how you
can best help to ensure <community> is becoming more dementia capable?
☐ Yes ☐ No
Reference: Minnesota Department of Health, Community Health Promotion — Mobilizing Your Community to Promote Health,
http://www.health.state.mn.us/divs/hpcd/chp/hpkit/pdf/involv_ws2.PDF, viewed 6/29/12.
Community Needs Assessment — Legal Counsel/Future Planning Survey
www.ACTonALZ.org
©2014. This toolkit was made possible by funding from the Greater Twin Cities United Way.
Page 5 of 5
Rev. 06/05/14