Intimacy, Sexuality and Sexual Behavior in Dementia

Appendix C
Sexuality and Intimacy Worksheet
Sexuality Guide 22
1. Description of the observed behaviors from team (including
family):________________________________________________________
_____________________________________________________________
2. Assessment of competency (See Lichtenberg, 1997 for example of
assessment, page 9 of this document):
_____________________________________________________________
_____________________________________________________________
3. Beliefs and values:
• resident:
_____________________________________________________
• family:
______________________________________________________
• staff (personal and professional):
______________________________________________________
4. Any differences within team regarding beliefs and values? Are they
resolvable? Can the team come to a compromise? If the resident cannot
participate in decision-making about the relationship, then what does the
family say about it continuing?:
_____________________________________________________________
_____________________________________________________________
5. Given the differences and/or compromises made, what are the circumstances
and conditions (parameters) under which the relationship or behavior will
continue?:
_____________________________________________________________
_____________________________________________________________
6. List specific interventions identified for the situation:
_____________________________________________________________
_____________________________________________________________
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