Alzheimer's Support Network



Have You Completed or Signed-Up for the Following as Part of Your Emergency Plan?


1.  File of Life                                                                             Yes _____           No _____              Link:  File of Life

2.  Typical Day Sheet                                                                Yes _____           No _____              Link: A Typical Day 

3.  Wanderer’s Identification Program                                Yes _____           No _____               Link:   Wanderer's ID Program

4.  Project Lifesaver                                                                 Yes _____           No _____               Link:   Project Lifesaver

5.  Advanced Directives:

              Durable Power of Attorney                                     Yes _____           No _____                 Talk with your attorney

              Designation of Health Care Surrogate                   Yes _____           No _____                 Link:  Simple Form
              Florida Living Will Declaration                                 Yes _____           No _____                Link:  Example    Advance Care Kit
              Health Information (HIPPA) Release                      Yes _____           No _____                 Link:  Example    HIPPA From

6.  Financial Logs                                                                      Yes _____           No _____                  Link:   Part 1      Part 2

7.  Pre-Selection of two (2) Facilities                                    Yes _____           No _____                  Talk with us at the Alz Support Network

8.   Special Needs Shelter Registration                                 Yes _____           No _____                  Link:  Shelter Application 

We will assist you in getting all the above completed.  If you answered “No” to any of the above and would like some help, please talk to us at the Alzheimer’s Support Network.

To sign up for Programs with the Senior Crime Prevention Unit, Seniors at Risk, and Free cell phones (for 911 use only)  
Call:    (239) 252-0722


Name:   ___________________________                          Date:  ______________

Click here for the PDF version of the Emergency Preparedness Checklist.  You can download and print this.

for a Caregiver Emergency


Have you ever said to yourself 


• What would happen to my loved one with Alzheimer’s or dementia if I became ill or had an accident?


• Who would take care of my loved one if I had to be hospitalized?


(What happens if there is no family to help, or all children and/or siblings live out of town, or the neighbors you count on are out of town?)


Here are some suggestions on how to be prepared for the emergency that we all hope will never come:


Have a Contingency Plan.

Ask yourself: Where would my loved one go or who would come to my home and be

with my spouse?


Remember the 2-2-2 Rule

Who could care for my loved one for the first two hours at the time of an emergency?

Consider friends and neighbors, your church, members of your support network.


Who could help for the first two days?

Consider pre-registering with a facility, home health agency - other resources that could care for your loved one for two days, possibly until family members could come.


Who could help for Two Weeks?

Consider which family members might come for two weeks if you were seriously ill.

Would your loved one need to go to a facility? If so, can you pre-register?

(Call the Alzheimer's Support Network at 262-8388 for help developing a 2-2-2 plan.)


Complete a ''Typical Day” Sheet

Describe a typical day for your loved one. Include such items as:

Medications (what times are they taken, does the person need help?)

Food likes and dislikes (don't forget any food allergies)

Does he or she go for a walk?

Is there a favorite TV show?

Does he or she need help in the bathroom? Wear protective garments?

What other information might help someone caring for your loved one?

Send a copy of this sheet to your family. Put a copy with your File of Life. Give a copy to your friend or neighbor.  The more you are able to communicate what a typical day is in the life your loved one with dementia, the easier the care will be in your absence.


File of Life:

The File of Life program is a free, comprehensive program that places vital personal

health information prominent locations.  Emergency Medical Technicians (EMT’s) Police, and Fire Department personal are trained to look for File of Life information in the home and on your person.  . We str.ongly recommend that you complete a "File of Life" for both you and your loved one.   Click here for the File of Life



Emergency Information needed for temporary placement in a facility.

1.  The 1823 Form becomes doctor's orders for the facility.  We have blanks in our office for you to take to your doctor to complete. You keep the form until you need it. It Must  be updated quarterly.

2. Durable Power of Attorney (DPOA) - for legal and financial decisions.

3. Health Care Surrogate - for medical decisions.

4. Living Will - for end of life decisions.

5. Health Information (HIPPA) release- for release medical information

6. Typical Day Sheet- probably the most important for your loved one's comfort during an emergency placement.  The typical day gives the facility practical information to care for them properly.

7. List of contact names and phone numbers so that the facility can keep family

updated and problem solve when necessary.


Additional programs that are important for your planning:


Wanderer's Identification Program.  The Alzheimer's Support Network together with local law enforcement provides the Wanderer's Identification Program - a special registry that can help reunite loved ones with those who have wandered away. A bracelet or "dog tag" is provided.   Click here for Wanderer's ID Program.


Other options (fees involved):


Project LifeSaver (a national program to identify potential wanderers.)


Medical Alert Systems


Senior Connection Program

The Senior Connection Program utilizes volunteers to call and check on seniors Monday through Friday. This program can give you and your out of town family peace of mind on a daily basis.


Special Needs Shelter is organized by the Collier County Emergency Management Department.


They have taken into account the needs of our families dealing with dementia and have created a place where we can go during an emergency such as hurricane.

Register by calling (239) 774-8444. They will send you an information packet to fill out regarding medical condition and needs. Know that you don't have to go if you register.  It is always your option. If you go, they will see to it that your animals are cared for also. Click for more Information on the Special Needs Shelter.  Click for Application.


Click here for a PDF file of Planning for A Caregiver Emergency that you can download and print.



This is your plan to have someone care for your loved one if you became ill or had an accident. The following people have agreed to give care in an emergency.



2 hours:              Primary                                Alternate


Name                 _______________________             __________________________

Address             _______________________                 __________________________

City                  _______________________               __________________________
Phone               _______________________               __________________________



2 Days:


Name                 _______________________             __________________________

Address             _______________________                 __________________________

City                  _______________________               __________________________
Phone               _______________________               __________________________




2 Weeks:


Name                 _______________________             __________________________

Address             _______________________                 __________________________

City                  _______________________               __________________________
Phone               _______________________               __________________________



Each of the above have been given a copy of this sheet and a copy of" A Typical Day" schedule which includes any information about Day Care Centers if appropriate.

Click here for a PDF file of The 2-2-2 Emergency Plan Sheet that you can download and print.

Click Logo Above for More

 Click here for  A TYPCIAL DAY form

Click here for information on the Wanderer's Identification Program  (WIP)

Legal Preparedness


Durable General Powers of Attorney. Under a Durable General Power of Attorney you authorize individuals to perform financial matters on your behalf. The Power of Attorney can be designed to become effective upon its execution or upon the Principle's incapacity.  Query whether advisable to tie to incapacity as that is a high threshold and it may assist your family for your attorney-in-fact to be able to act in  instances where you remain capable but are either unavailable or in poor health.




If you name a contemporary as your attorney-in-fact, give consideration to naming an alternate attorney-in-fact should your contemporary fail or cease to act.


Your power of attorney should include durable language found in the Florida Statutes. This ensures that your power of attorney will remain viable should become incapacitated.


Your power of attorney should specifically state that your attorney-in-fact may sell your homestead residence. A reference to selling real property is not sufficient to cover transactions related to your homestead.


Advance Directives. Under an Advance Directive you name a health care surrogate who you authorize to make your health care decisions should you no longer be able to do so. The Advance Directive also typically includes a Living Will under which you state your preferences regarding the withholding of artificial means of life support.


An Advance Directive is not a ''Do Not Resuscitate Order'' (DNR). A DNR can only be obtained from your physician. 




Consider naming alternate health care surrogates in case your first named surrogate is unavailable or unable to act.


Review Living Will provisions carefully with your legal and medical advisors to determine whether they accurately reflect your intent. To extent you wish to provide greater guidance to your family members and loved ones, consider some of the options outlined in the Five Wishes document. It is preferable to have one document versus multiple to avoid conflicts. Accordingly, if you're interested in the Five Wishes format, make sure that you revoke any prior Living Will you may have signed previously.


Provide copies of your Advance Directive to your health care providers. Also keep a copy

in your glove compartment in your car.


HIPAA Waivers. Under a HIPAA Waiver you authorize your physicians to release your medical information to certain named individuals. Under the current privacy laws, this is

an important document to ensure communication between your physician and your health care surrogate(s), as well as with any other individuals you want to include.




Make sure your HIPA Waiver authorizes your physicians to release information regarding your capacity to your attorney and to any Trustee(s) for trusts you may have created or may be a beneficiary under. Many of your legal documents are hinged on your capacity, so it is important that your legal advisors and fiduciaries can obtain this information from your doctors.



Preneed Guardian Designation. If you plan properly, in most instances it will not be necessary to have a guardian appointed to manage your person or your finances (i.e., should you become incapacitated). Nonetheless, you can sign a preneed guardian designation wherein you specify your preferences regarding the appointment of a guardian should one be required. By designating your preferences, you hopefully avoid, if not limit, the conflicts that might otherwise arise within your family.


Wills and Trusts. Your estate plan should be reviewed periodically with your attorney to ensure that it is up to date, both from a legal perspective and from your personal family situation. As part of this process it is important that you consider how your assets are titled. In preparing for incapacity, there may be reasons for changing title from an individual's name or from joint ownership to some form of trust arrangement.




The laws governing homestead are complicated. Care should always be taken as far as title changes related to the homestead, both from the standpoint of maintaining your Save Your   Homes exemption and protecting your equity from creditors.



Location of Important Documents. We recommend that you permit your attorney to retain your original Powers of Attorney, Advance Directives, HIPAA Waivers and other estate planning documents.  Most attorneys maintain an offsite vault for storage. By placing your originals in this location you afford protection from destruction and also you simplify the management of your affairs. The attorney can access the documents typically within a day and can attest to a requesting party that the original exists and has not been revoked. In most cases, the original will then not have to be released, providing for its continued safe-keeping.


If you would like to arrange an appointment or have any questions regarding the presentation, please contact:


Alison K. Douglas 

Cummings & Lockwood LLC

3001 Tamiami Trail North  Naples, FL 3103

Phone: 239. 649.3160 (Secretary Annette Keeney)

Click here for a PDF of Legal Preparedness which you can download and print.

Click here for a PDF of the
AHCA 1823 Form

What is the Senior Connection Program?


Seniors who live alone or have medical conditions receive daily phone calls by volunteers. If contact cannot be made, a designated key holder is notified or an onsite visit is conducted by a law enforcement officer.


Contact our Seniors Crime Assistance Unit at 252-0722 to sign up for this voluntary service.


You will be asked to:

1) Complete a Senior Connection Program form over the phone. You will be asked how frequently you want to be called. They will give you their choices to choose from. We suggest daily, Monday through Friday.


2) A key holder will have to be established, which will be their point of contact if they are unable to contact you. The key holder needs to be someone that is willing to check on you in the event you do not answer your phone at the designated time. This person must be local. Name and phone number where they can be reached during the day is required for the program to work.


3) Give emergency contact information; name, address, phone number and relationship to person is required in case of an emergency. This information needs to be updated on an annual basis. If there is a change in address or key holder you are required to make this information available.


You will need to be available to answer the phone at the designated time and day. Failure to do this on two separate occasions will cause cancellation of the program. If you have an appointment or for some other reason you would not be able to be available for the call, you are required to call the Sheriff’s office, 252-0722, and notify the volunteer that calls you each morning, or leave a message.

Click here for a PDF of the Senior Connection Program which you can download and print.

Click here for a PDF of How to Interview an Agency which you can download and print.

These are forms to place  Your Contact Information:  Medical and Dental, Friends and Family

Fill in this form so your loved ones can find the  Location of Important Documents

Click here for a PDF of A Checklist for a Widowed Person which ou can download and print.

Florida Brain Bank:  Click here for State of Florida Brain Bank 
   Click here for PDF of 
Fact Sheet and General Information

 Advanced Planning  from Fuller Funeral Home