DSMP Plus Leader Resources
Includes workshop material for Take Charge of Your Diabetes Plus (DSMP+).
Participants can choose one of the following options when completing paperwork:
- Complete a paper form or fillable PDF
Upon workshop completion, email all workshop forms to joan.fox@ageoptions.org
DSMP+ Guides for Leaders & RD
Data Collection Checklist- Instructions for data collection from registration to last session In-person workshops - Virtual workshops
DSMP+ Workshop Forms Sample Packet- Contains all required forms needed for DSMP+ In-person workshops - Virtual workshops
ILPTH Program Quick Reference- Program guidance for facilitating DSMP Plus. Details regarding max number of participants, cut off for new participants to join, workshop length and session time. DSMP Plus will follow same rules for group workshops as Take Charge.
Workshop Forms
Session 1- Individual Assessment
Participant Welcome Letter- For virtual workshops.
Session 1 Data Collection Script- To be read aloud to participants during Session 1
Session 1 Virtual Data Collection Script- To be read aloud to participants during Session 1
Legal Forms for Participants:
- Participant Registration Form
- Acknowledgement of Privacy Policy
- Liability Waiver
- Insurance Authorization and Release of Information
- Photo Media Release- This form is optional; to be used if collecting testimonials or taking pictures. Feel free to edit to add your organization's information.
DSMES Order forms:
- Provider Letter for DSMES Order- Cover letter participants are to send along with DSMES Order Form to their physician.
- DSMES Order Form- Participant needs to submit this form to their physician for completion and return the document signed.
Participant Assessment/Pre-Survey- English
Intervention Tracking Form/Attendance Record- To be completed by RD during individual sessions, and by leaders during each group workshop session.
SMART Goal Participant Sheet- Completed by RD. It is to be given to participants to retain as reference for their goal during the workshop.
Session 2 (1st Group Session) Handouts for Participants
(One form per participant)
Workshop Overview and Homework by Session
Menu Planning DSMP Charts 9 & 10
Session 7 Forms (Last Group Session)
Participant Post-Survey- English
Session 8- Individual Follow-up Session
Participant Support Plan- RD completes collaboratively with each participant.
Provider Follow-Up Letter- Cover letter program coordinator is to send along with Support Plan to the participant's physician.
3 Month Follow-up
Participant Follow-Up Letter- Cover letter program coordinator is to send along with Follow-Up Survey to the participant.
Participant Follow-Up Survey- English
Links and Other Materials
SMRC Leader Certification Guidelines
Pre-workshop Checklist and Participant Recruitment Plan
Email Templates- For leaders to send to participants for online workshops
Zoom Instructions- (Provided by Rush) For online workshops
Participant Certificate of Completion Template
Crisis Intervention Plan- Provides general guidance about what to do in crisis situations
Receipt Template for Books/CD's
Take Charge of Your Pain Digital MEP Audio- The Take Charge of Your Pain Digital MEP (Moving Easy Program) audio is available for free to play at the following link: https://www.bullpub.com/mep.html
Brief Body Scan- Contact us if you would like to purchase a CD. You may also Google or use YouTube to find a meditation.
Marketing Materials
ILPTH Evidence Based Program Flyer
Take Charge Series Program Flyer
ILPTH Outreach Toolkit Template- This Toolkit includes templates for flyers, posters, social media posts, etc. You will need to have a Canva account to access the template and create a COPY to make edits (DO NOT EDIT THE TEMPLATE). If you need help doing so, please refer to our ILPTH Outreach Toolkit User Guide.