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 LetterFor 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:

DSMES Order forms:

  • Provider Letter for DSMES Order- Cover letter participants are to send along with DSMES Order Form to their physician. 
  • DSMES Order FormParticipant needs to submit this form to their physician for completion and return the document signed.

Participant Assessment/Pre-Survey- English

Intervention Tracking Form/Attendance RecordTo 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 1

Menu Planning 2

Menu Planning DSMP Charts 9 & 10

Session 7 Forms (Last Group Session)

Participant Post-Survey- English

Session 8- Individual Follow-up Session

Participant Support PlanRD 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

Workshop 101

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

Fidelity Visit Checklist

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

IL Pathways to Health Logo

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.