Alzheimer Society Referral Form
For people living with dementia, their care partners and professional referrals.
Please note there are mandatory fields in this form. You will need to complete all mandatory fields marked with an "*" before submitting the form. Once you have submitted the form, someone from our Intake team will reach out to the main contact indicated.
Today's Date
*
-
Month
-
Day
Year
Date
Is this a self or professional referral?
*
For myself
On behalf of my family/friend/person I support
Professional referral (physican office, police, hospital, etc)
Internal ALZSWP referral * for ALZSWP staff only
I consent or have received consent to refer? (Please note that all of our programs/services are voluntary. The individual you are completing this form for and/or being referred, must consent to receiving services from us.)
*
Yes
No
You have indicated that the individual has not provided consent to receive services from our organization. Please note that the person being referred must be informed and agree to you completing this form on their behalf, and they should be willing to engage in services. At this time, we are unable to proceed with the referral. If you have any questions or require further assistance, we encourage you to contact our office directly.
Middlesex-London office (519) 680-2404
Elgin Office (519) 633-4396
Oxford Office (519) 421-2466
Internal ALZSWP team member name making referral
*
I am referring:
*
Person living with dementia only
Care partner only
Both
Please select the area of residence for the Person living with dementia:
*
London-Middlesex
Elgin
Oxford
Name of Person Living with Dementia
*
First Name
Last Name
Date of Birth of Person Living with Dementia
*
-
Month
-
Day
Year
Date
Address of Person Living with Dementia
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Card Number of Person Living with Dementia
Name of Care Partner
*
First Name
Last Name
Date of birth of Care Partner
*
-
Month
-
Day
Year
Date
Address of Care Partner
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Card of Care Partner
Type of Care partner
*
Spouse/partner of Person Living with Dementia
Child of Person Living with Dementia
Friend/Neighbour of Person Living with Dementia
Sibling of Person Living with Dementia
Other
Main contact is:
*
Person living with dementia
Care Partner
Other
Phone Number for contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Preferred Language of Communication
*
English
French
Other
Referral Source Name & Agency (please list your name and place of work)
*
Referral Source Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Email
example@example.com
Please contact:
*
Person Living with dementia only
Care partner only
Both
Does this referral require urgent attention from our Behavioural support team?
*
Yes, this referral should be directed to BSO
No, this referral does not require urgent BSO attention
Please upload medical history and/or documents to support this referral if applicable
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Cognitive Diagnosis of Person Living with Dementia
*
Under Investigation
Mild Cognitive Impairement
Frontotemporal Dementia
Alzheimer's disease
Vascular Dementia
Lewy Body Dementia
Other
Reason for Referral (please select all that apply) - Please note : We do not provide diagnostic services or support Long term care applications
*
Recently diagnosed
Emotional Support
Living arrangement/Transition support
Changes in Behaviour
Information/Education
Safety Concerns
Finding Community Supports
Staying Socially and/or Physically engaged
Other
Additional notes
Known Risks (please select all that apply)
*
Family dynamics
Recent hospitalization(s)
Infectious disease
Infestation/squalor
Pets
Physical Environment
Smoking
Weapons
No known risks
Other
Submit
Should be Empty: